Severe dementia referral

[Anewby]

I am fairly new to home health, but have been a nurse since 2010.

Yesterday, I went to an assisted living facility to see a patient on the Memory Care Unit. When I arrived and assessed the patient, I realized she was an end-stage dementia patient, and had no nursing needs.

I spoke with the Charge Nurse on the unit who informed me she'd had multiple falls without any fall reflexes/safety awareness and also believed she was an end-stage dementia patient. So my thought was that the patient would not benefit from PT/OT due to her inability to remember any skills that would be taught during sessions.

I called the office to let them know, and my manager was not happy with me for not admitting the patient to our service. It just does not make sense to me to admit her. What would you have done?

[Libby1987]

Because of the falls, I would have admitted and allowed PT and OT to do their evals and make determination for their services.

Actually, with a nurse on staff we wouldn't have had made a nursing eval, it would have been performed by PT.

[toomuchbaloney]

Would this end stage/advanced dementia patient be a better fit for hospice care and services?

[MrChicagoRN, RN]

Because of the falls, I would have admitted and allowed PT and OT to do their evals and make determination for their services.

Actually, with a nurse on staff we wouldn't have had made a nursing eval, it would have been performed by PT.

Yes, I was thinking PT/OT safety eval, perhaps some strengthening exercises:maybe the family would come in and do them.

[toomuchbaloney]

Yes, I was thinking PT/OT safety eval, perhaps some strengthening exercises:maybe the family would come in and do them.

What are the goals for this elderly woman who has "end stage" "advanced dementia"?

At some point it is anticipated that the "end stage" or "advanced dementia" patient will completely lose the ability to ambulate safely or unassisted. Efforts to stop or slow that are likely exercises similar in efficacy to spitting into the wind, IMHO.

In my view, that sort of intervention actually doesn't serve the patient, does not have realistic goals, and adds unnecessary costs to end of life health care.

[Anewby]

I believe she is getting close to needing a hospice consult. As far as family, the nurse said her family is not involved in her care and rarely visit. She was not able to ambulate unassisted. She was A&OX1, could not even tell me her DOB. I truly believe PT/OT would not have done her an ounce of good.

[Libby1987]

She's had multiple falls in an ALF, getting a PT eval is pretty standard if only to confirm that her mobility being managed properly, it doesn't mean they're going to provide a full POC. She'd probably be a LUPA but they're going to occur from time to time.

Our Hospice seems to be having tightened admission criteria and advanced dementia alone won't qualify.

[toomuchbaloney]

She's had multiple falls in an ALF, getting a PT eval is pretty standard if only to confirm that her mobility being managed properly, it doesn't mean they're going to provide a full POC. She'd probably be a LUPA but they're going to occur from time to time.

Our Hospice seems to be having tightened admission criteria and advanced dementia alone won't qualify.

In my experience, advanced dementia patients who are on a declining trajectory generally have other health issues which make it reasonable and relatively easy to admit them for the 6 month window that CMS allows. During that time the team can work diligently to make the person more comfortable, to develop a POC which reflects the EOL goals for that elderly patient, and then continually assess them with intention to discharge should their decline plateau and their symptoms and status become more stable.

[Red Kryptonite]

Our Hospice seems to be having tightened admission criteria and advanced dementia alone won't qualify.

It's not your hospice, it's Medicare.

Anewby, she's had multiple falls and can no longer walk independently, which shows physical decline. Is she incontinent? Is she losing weight? Does she refuse to eat or have trouble swallowing?

Dementia by itself no longer qualifies as a Medicare reimbursable hospice diagnosis. But dementia along with signs of advancing decline like what I asked you about can be.

[Libby1987]

I meant that our agency is dealing with tightened criteria but not by their own design. I realize it's Medicare but I cannot say that all agencies tow the line like ours does. Oversight and denials wouldn't be necessary if they all did.

[amillion3147]

I am a PT. We have to assess any and all pts that fall because of course fall indicate a balance problem which goes hand in hand with poor safety, decrease muscle strength, poor vision etc. I have over 10 years experience with Alzheimers related dementia. While therapy is not a remedy for everyone with the disease it is of some benefit at all the stages. I enjoy the population because many assume just because they have dementia there is nothing that can be done. That is far from the truth. While we can't change the disease process we can do alot to reduce the fall risk. Iv'e worked with pts that could barely follow simple commands but I got them steadier on their feet.

It is not in the scope of your pratice to determine if someone needs PT or not. We make that judgement call as therapists. Best thing is to make the referral and let us do the eval.

[Libby1987]

^^^^^that^^^^^