Questions re: hospice/skilled nursing at facility vs. home?

[nervousnurse, ASN]

I'm VERY NEW to the LTC/SNF world and am so curious about things that there is NO TIME

to ask about at work.....so I thought I'd ask all of you. :)

I've seen a couple of our hospice residents die alone even though they have hospice personnel coming to see them at our facility. One died VERY SOON after a hospice person had visited him (I don't know if she was an aide or a nurse, I wasn't taking care of him and was too busy dealing with a million other things--again, I'm just curious because I thought they usually had someone with them when death seemed very near). I'm curious about how often hospice patients die alone and also,

is there a specific reason why some people would be in a Nursing Home/ SNF versus at home? Is it the patient's/ families choice to be at home versus a facility?

Next question has to do with home health versus being in a SF/ NH. We have a relatively young person who will be getting short-term. OT (only for strengthening), some meds, a very SIMPLE dressing change, and they need minimal-no assist w/ transfers. Wouldn't it be less expensive (and easier on them?) to get these services at home? The plan is for them to be home in a few weeks.

Again, just curious and there are so many details and things to learn that I don't understand yet. One thing I do know is we are ALWAYS hearing about money and that's what makes me wonder why someone as described above would need to reside full-time in our facility, especially when they should be able to go home in a few weeks.

Thanks in advance.

[chrisrn24]

It's actually more expensive, I believe in many cases, to have a nurse drive out to the house and perform these tasks. That's what I've heard anyway. And a lot of times they aren't covered.

And you may not know the extent of her situation...maybe she is a hoarder and services won't come to her house, for example. Maybe she is escaping an abusive situation. There is a reason behind it, definitely.

And as for people in the home on hospice, a lot of it is what the family can or cannot do...too emotional, etc.

[nursemom123]

Hi Nervous,

I agree with chrisrn24, many times when things don't "seem right" there is usually a back story somewhere. Often a younger person is unable to be compliant for a variety of reasons, oftentimes not their fault, and keeping them in a SNF for a short period of time is actually more therapeutic and less expensive then sending them home and then readmitting them back to the hospital when the wound gets infected or they become contracted or whatever.

I do know that hospice tries to make sure someone is with the patient if they are dying. It is usually the patient's choice where services are provided. Hospice can provide services anywhere - SNFs, ALFs, private homes, in-patient units, hospice houses, trailers, we have even done hospice visits in homeless camps because the patient was AO4 and wanted to stay in place. If you see a hospice patient in your facility that you feel is actively dying or is having new symptoms, you can request the hospice company to provide crisis care (a/k/a continuous care), which is short-term 24 hour care for the patient. Patients on crisis care have to be assessed by a hospice nurse daily to maintain their crisis care status. CMS has really been hitting hospices hard the last few years for giving crisis care that CMS feels is not warranted. If the patient receives crisis care and they are stable, then that is considered fraudulent billing, usually Medicare/Medicaid fraud, and with the tight federal budget, hospices all over the country are being audited for this. Under CMS regulations, "actively dying" is not considered a valid reason for crisis care, it is considered the expected outcome. Hey, I couldn't make this stuff up.

So if you see a patient on hospice that is declining, find a "new symptom", which could be anything - increased pain, confusion, anxiety, agitation, decreased LOC, N/V, dyspnea, respiratory distress, fever, diarrhea, constipation, etc, are all considered valid new symptoms that could trigger crisis care. Follow your facility protocol for contacting hospice and request an evaluation for CC. And your facility should have a hospice nurse that does at least weekly visits on each of their patients...make friends with her, she can be a valuable resource for you. There may even be several hospice companies coming to your facility, get to know them all.

Good luck in your nursing career! It sounds like you really care about your patients and are doing a wonderful job.

[CapeCodMermaid, RN]

Hospice does not provide 24 hour care at home. Many people are simply too ill or their families not capable of providing the care they need. So they have hospice in the SNF which is an adjunct to the care the SNF staff gives them.

Home health...so much depends on the company and the patient's insurance. Some companies will only make a visit once a day so if they have a twice daily dressing change or an IV med more than once a day, it is cheaper to have them cared for in the SNF.

[nervousnurse, ASN]

Thank you for your answers!