volsfan

I wanted to add that you must also consider that the families and patient's can choose whether or not to treat an infection.

All I can tell you is that is our company's policy; whether it is right or wrong I don't know. I can see both sides of the argument. We open the kit to explain all the meds to the pt, but they are already labeled with their name on it. We then close and seal it and it is to remain sealed until we receive a future MD order and instruct the family regarding this. This brings up a good point though about the legalities and ethics. Anyone know the legal laws regarding this topic? Where could I look? Do you think it is by state?

Although our MD has to sign for us to have the comfort pak in the home (from HP) we are suppose to get another order to use any of the medications in the kit. If we start using a med from the kit we get them then add it to their routine meds; and order it PRN. Example: A pt is having moderate to severe aggitation in the middle of the night and the on call staff starts him on Ativan from the comfort pak, per MD orders she obtains. The RN Case Manager arrives the next day and he has had two doses which are working well. The medication would be added to his routine med list and a prescription bottle of it ordered. Two months later the pt revokes. The nurse would destroy the Comfort pak; but the pt still has his Ativan b/c it was ordered as a routine med AND in collaborating with the physician who will take care of the pt after revocation; usually due to going to hospital they would be supplied with a medication list which has the Ativan on it. So, the pt is not without. It is in the patient's name. The comfort pak includes: Ativan, Morphine, Haldol, Atropine, Compazine, Tylenol supp. On the kit it states DO NOT OPEN UNLESS A MD OR NURSE TELLS YOU TO. Therefore, once they are off service they will not have a nurse/md telling them to do anything with it.

All our staff is salary; including on call staff. The starting salary is $24.00/hr. Our case loads are b/t 12-15, but can get as high as 17-18. When the RN Case Manager is on call (backup/primary) they get paid a minimal daily rate, it's under $10.00, nothing to get excited about. If we have to go out to make a visit then we get anywhere from $25.00-$150 depending on the time; usually the visit is $25,00 to $50.00, rarely more. However, the time does not include travel; which can be a problem. It is really not worth it to be on call IMO, but like I said we only do it for 6 weeks out of the year; which is much better than the place I came from and doable. Every hospice RN Case Manager in our area has to work call; no matter who they work for. Nobody likes being on call, but it is a fact of life. Leda1st, since you guys are salary and don't have on call staff it's really not fair. When I worked so much on call at my last place we were hourly so at least we were compensated well.

Our company has 2 FT and 1 PT on call staff who work primary call. The RN Case Managers rotate backup call; and will take primary call if the on call staff are sick or on vacation. Mon-Fri: 1 primary (depends on day of who it is) with a backup RN Case Mgr Sat/Sun: 1 primary on call works (8 am - 8 pm); the other works the (8 pm - 8 am); the part time on call staff member works 12 noon-8 pm and then the RN Case Manager is backup. About 6 months ago we moved to having the RN Case Mgr doing 1 whole week call at a time, giving us call every 8 weeks. As a case manager I didn't like this at first, but now enjoy knowing I am on call only 6 weeks out of the year. However, there will be times that the Case Manager will be out many nights during a given week; so if this happens I would make sure they get enough sleep and check to see if they need help with their case load. This is usually rare, but it does happen. I know not all hospices can have the staff we do. I came from a smaller one and we were on call every other weekend working 24 hour shifts. Our average LOS was low, like 25 days and every weekend we averaged 2-3 inpatients who would die. So, basically we busted our tails. It just didn't work; case mgrs got sick and burnt out. Our staff turnover rate was extremely high there. And I guarantee pt care suffered due to the staff being tired all the time. If you don't have designated on call staff I recommend sitting down with your case managers and collaborating on a schedule. If they are part of the process they will accept the decisions better and may make your job easier by coming up with something all on their own.

I would find out why the management thinks this way; where are they coming from. Is it b/c they are misinterpreting some law, policy, etc. I am in total agreement with Katillac. Many times the pt will have already been on narcotics when they came on hospice it is crazy to think you would destroy those meds when they revoke. The only thing our hospice destroys is the Comfort Pak and if we have been using medications from that pak we would have gotten them a regular prescription for it anyway.

There is also a difference in how Medicare pays. They will pay significantly more for someone to be on Inpatient care.

Per the COPs: The initial assessment must be done within 48 hours, by an RN. The comprehensive assessment must be done within 5 days; this includes the psychosocial (social worker) and spiritual (chaplin) assessment. The family can defer the social work and chaplain, so this would be documented as part of the comprehensive assessment; and as an RN we do assess for spiritual and psychosocial needs. However, a hospice company can have a policy that is more strict than the COP guidelines. Hope this helps.

Many hospices use ekits b/c they are cheaper to have than getting each of the medications individually.

To pjtk, As a home hospice nurse I review all comfort pak contents with my families b/c the families are usually the first to give the medications in the middle of the night or on weekends while they await for the weekend nurse to arrive. I have found it to be a good practice since there are multiple medications and when there is an "emergency" for the families they should be educated and feel comfortable about the contents of the kit. If they are left uneducated they are more likely to make a mistake if the hospice nurse is trying to instruct them over the phone. This generally takes an additional 20-30 minutes to review during a visit, but it sure does help. I would call the hospice you are with and speak with the manager. If how your nurse treated you is the company policy regarding the kits I would interview other hospices. If not, I would request a different nurse. Education is the major part of our job and at the very least she/he should have spoke to you in greater detail regarding the kit. Gail

An average day: 7:15-7:30 See first pt of the day (I like to get started early, you will find if you start prior to 8 AM it works better) Work until 1030-1100 seeing pts. Take a break for lunch, b/t 15 minutes to 1 hour. Depending on if eating with coworkers or took my lunch 1200-1500 Finish up seeing pts and/or go to scheduled meetings. 1500-? Go home and finish up any documentation needed. I see most of my home pts twice weekly; carrying a caseload of 15 pts on average and average 5 visits per day. My home pts know I will be there on what days and around a certain time of day; such as early morning, mid morning, midday, etc. I always call if I am going to be "late" and let them know I have been delayed. So, if I have to bump a pt from early morning to midday I certainly call. When I get a new pt on service I fill them into a open spot. You have to be flexible in this job. You will get to know which pts you could even bump to a different day and which ones you just need to keep on schedule. If I have a cont. care case going I make a call first thing to see how they did overnight. If they are "comfortable" then I fit their daily visit in based on location; if not then I will see them first thing. If your company doesn't do CC cases, but you have a pt not doing well I would do the same thing. I agree: carry extra supplies, restock as soon as you run low; extra forms organized in a binder; program all numbers in phone including pts. I put pt and then pt name so when I scroll for the name it is easier b/c it goes straight to all the pts. Example: Pt Smith Recerts: We are lucky that we are on computer, we have a screen that tells us when the next one is due. My old employer did not, but during all Monday morning meetings we were given our census printed and it told us any upcoming recerts that would be due. I always turn them in 1-2 weeks prior so they can get them signed. If you don't have those luxuries I would get a calendar and on admission of a new pt put in their recert dates, going out 6 months or so. Even better would be using MS Outlook and doing a recurring event. That way when they die/revoke/discharged you can just delete the recurring event and not worry about missing something. And you wouldn't have to count. Well, I have much more, but got to get my day going!

If the pt is in the hospital on INPATIENT STATUS and not outside the plan of care, the COPs (Alabama) require a member of the IDT to visit 6 days per week. You would need to check your particular state to see if it is different. Most hospices here require a 7 day per week nurse to visit b/c other members of the IDT cannot write physicians orders and if they are on inpatient status they most likely will need changes to their plan of care. If the pt is in the hospital outside the plan of care then the COPs do not require the daily visits, just your routine weekly visit. I am assuming this is your case since they use to not require it and now they do. If this is so I would find out why they changed it. My guess; the loss of a pt to another hospice once they returned home or a family member upset b/c a hospice did not visit at all while they were there. If the pt is going to the hospital outside your coverage area they should be discharged from service if it is more than a couple of days. The reason being is that you cannot manage their care if they are not in your service area. Once they are discharged from the hospital you could pick them back up.

She shouldn't have to pay out of pocket since it is related to her diagnosis and would not really be considered aggressive tx, at least that's how my hospice would view it. I know all of them view aggressiveness a little different. But, ours would say you are treating a symptom rather than the disease and if it helps it would improve her quality of life for a brief period of time. I would have to do some research, but I don't know that TPN really would prolong life at this stage.

TNP is appropriate in the hospice and home setting. But always remember it's about quality of life. If the TPN will bring improved quality to her life to her, even for a short period of time, then it sounds like it's worth it to her. When speaking with her about it I would explain that you will do a trial period of TPN, have a goal date to re-evaluate whether or not it is helping. I would also be very specific about the pros and CONS of TPN and review them when you start it. Good luck.

A good hospice company will not have the high turnover rate that other hospice companies do. I know this from personal experience. Our longest Case Manager has been with our branch for more than 6 years (basically since our branch opened); I have been there the shortest amount of time and that is right at one year. I came from another company that replaced at least one position every 6 weeks due to high staff turnover. For the most part the case managers hung in there for an average of 6 months (I almost made it a year). I think a lot of it has to do with the expectations of management, training and the overall structure. Many hospices I hear about (and the one I use to work for) require their case managers to do admissions, continuous care, and primary call every other week, with a case load of 18-20 patients. This is just too much in my opinion based on the emotional and mental work you do. If you are providing continuous care for a patient then who is watching over all your other patients.? I could go on, but that would just be ranting. Gail Y, RN CHPN