This isn't the hospice I used to know

[jeannepaul]

When I started in hospice 13 years ago, we had certain diagnosis we could use: ALS, dementia, renal, cardiac, et al. There was specific criteria which had to be met. They could see their attending but could not see any specialists for the diagnosis we admitted them for. If they were still wanting to get treatment or voiced they would go to hospital, they were not ready for hospice. We used Roxanol, Ativan, scope patches, phenergan, bisacodyl, Tylenol and ABH in our comfort kits which were sent to every pt admitted and these meds worked great at controlling symptoms.

when families called after hours, it was because the pt was sob, in pain and/or scared and their loved one was dying. I would do a lot of teaching about signs and symptoms, calm the pt and assure the families they were doing a great job. It was a hard job time wise and emotionally, but very rewarding and I thought I would never do anything else but hospice.

fast forward......

They got rid of adult failure to thrive, but now the diagnosis of protein calorie malnutrition is used. Many other diagnosis which in years past, the medical examiner would question and has no disease specific criteria, is used all the time. The criteria seems to be recommended but if the doctor thinks they qualify, they get admitted.

Pts who would never qualify before, are being admitted. The medications we usedto use are no longer allowed because they'd are compounded and cost more, but trying to find something that works ends up costing more. And not everyone gets comfort kits on admission.

i get called out for itching, dressing changes, constipation, all on pt's that are not dying anytime soon, and more than likely not within 6 months. They can come on for "palliative care" and basically see and do anything they want and still receive the benefits of hospice.

we are managing diabetes, Coumadin, doing PT/INRs and other labs, IV antibiotics.

i feel this is not hospice anymore but level of care above hospice, but below home health. It takes an act of congress to get our c 2 meds, when before I would call up the local pharmacy, give them the order and the medication would be delivered. Now, we have to call an intermediary company enclara and they mail the medication after they receive the c2. If I need it now, I still have to call them so they can enter it into the computer, then wait before I can call a local pharmacy. They have to get in touch with doctor to get C 2 and then the pt will get their meds. It ends up taking up to 45 min to just make all of these phone calls.

i don't know if I'm just getting burned out, or just getting old but I don't like this "new" hospice. It's been the same with the last 3 hospices I worked at. I thought it was the company itself but it continues wherever I go.

I also wonder why do I care so much that people who don't really qualify, are getting on service, I should be thankful I have a job in this economy, but I do care.

anyone else having issues with the changes or is this localized? Or am I over reacting and just need to accept the changes or do I get out.

i would like to hear about some of the changes you are experiencing and how do you deal with it?

sorry so long, but thanks for reading!!

[heron, ASN, RN]

So, did you sign them on? Did you report that to a case manager, company compliance officer or the CMS fraud hotline?

[BerryhappyRN, MSN, RN]

Ohhhh jeannepaul how right you are! It is NOT the same! I am a hospice case manager for ALF's and boy do I get BS calls!!! Scabies, dry eyes, foot fungus, dandruff, EVERYTHING but what is related to their terminal illness. And to top it all off, 75% of the time when a facility sends our patient to the hospital THEY DON'T CALL HOSPICE! It is all so frustrating, it's maddening! Between ALF staff utilizing the hospice RN as the only RN in the facility, and worrying about "capturing" all ICD-10 codes for Medicare reimbursement, I am watching as my sweet, sweet, final true nursing career go down the drain.

We are being told to discharge if they don't show a decline, and at the same time admitting patients who CLEARLY will be alive a year from now. And if my dying patient loses weight AHCA has a fit and demands nutritional supplements!

We are so blessed to be able to provide comfort and support at EOL, but is that all going away? And your "Act of Congress" statement is spot on...only hard scripts??? For an actively dying patient??? REALLY??? My patient has bone cancer and you need a new hard scripts every 30 FREAKING DAYS??? REALLY???

Are other specialities dealing with this?

[BerryhappyRN, MSN, RN]

iowahomecarenurse what you are describing is frightening!

Luckily I work for a not for profit hospice, and Florida still has a few counties that require a "Certificate of Need" so we are the only hospice in 4 counties. We work diligently for our patients, providing excellent care to keep those Pseudo-Hospices out, but I used to think that Certificates of Need was bad for competition. I am starting to see the scams that some other hospices run, and hope to never have to be a part of them. Our company works very hard to keep a good reputation and take great care of our facilities/patients/families not just to keep all the business, but also to keep the facilities/patients/families safe from those Pseudo-Hospices you are referring to.

I agree, the only true oversight is Medicare and, well, it's government run so...

[heron, ASN, RN]

Yes - plus, in ltc, we're dealing with phantom hospice nurses who might, if we're lucky, show up once a month or so, make little or no attempt to communicate with facility staff and are nowhere to be found when careplanning actually takes place, let alone when a resident on hospice is in crisis.

As for providing the orientation to the hospice model of care, forget it. Yet the COP requires that hospices contract only with facilities where staff has had that orientation. Ongoing teaching of staff, as the primary caregivers (often the only "family" a resident has), is also part of the hospice nurse's job.

As a hpna certified hospice nurse, I know how to do the job right, and this is not what I see local hospice nurses doing.

My point being, alf/ltc admissions are treasured by hospice companies because they are exceptionally low-cost clients, making routine home-care more profitable. There are way too many inappropriate admissions, kept on service way too long and provided with the absolute bare minimum of attention.

This is not the fault of facility staff.

[sandygator, BSN, RN]

The fact that there was SO much fraud in Hospice has prompted CMS to take a closer look at and beef up regulations concerning Hospice care. Unfortunately, they have gone overboard with their regulations (as per usual when the government is involved). The closer scrutiny is both a good and bad thing. The bottom line, of course, is that Hospices must follow their regs or be denied payment. There is no negotiation. I'm glad to be retiring soon, because I do NOT like non-nursing entities dictating our practice....ever since the beginning of JACHO!