The diversity of care required to meet the individualized needs of each resident means that the director of nursing services (DNS) must seek the expertise of a variety of healthcare professionals and work collaboratively. When it comes to providing quality end-of-life care, hospice organizations are the experts and can be a welcome addition to the team during this time, benefiting both the resident, their family, and the facility. This article will provide tips on what nurse leaders should keep in mind when collaborating with a hospice organization and how to make the most of this partnership.
Why Collaborate with Hospice?
Collaboration with a hospice organization has many benefits. For residents and family members confronting end-of-life decisions, hospice staff are adept at having hard conversations. They have experience discussing options that are available or questions residents and families may not have considered. Incorporating hospice care can help all parties involved make a smooth transition, feel at peace with the decisions made, and assure family members their loved one is comfortable in their last days. It can also facilitate a higher level of care for the resident, while he or she stays in a familiar environment.
Additionally, collaborating with hospice can greatly help the nursing facility. Benefits to the nursing facility may include:
- Additional resources for education on topics such as pain management, advanced care planning, behavior management, and principles of death and dying
- Hospice certified nursing assistants (CNAs) to provide ADL care
- Additional staff to sit with a resident if one-on-one care is needed
- Provision of medications and supplies related to the hospice diagnosis
- Reduction in hospital admissions
- Expertise in pain and symptom management, especially at the end of life
When to Refer a Resident to Hospice
There is no set rule for when to refer a resident to hospice, other than upon a resident’s or resident representative’s request. However, it is also common that a resident or family will not initiate the referral until their physician or a representative from the facility opens a dialogue about the possibility of seeking hospice services. There are a few indicators that, when present, may signal facility staff that a conversation with the resident or responsible party regarding a hospice referral may be warranted.
- When a resident triggers multiple Quality Measures, staff may wish to consider a referral to hospice. Some Quality Measure to review include:
- Significant weight loss
- New or worsening pressure ulcers
- Need for help with ADLs has increased
- Ability to move independently worsens (long-stay)
- Residents who receive an anti-anxiety or hypnotic medication (long-stay)
- When a physician gives the resident a life-limiting diagnosis
- When resident or family are having difficulty coping with the end-of-life situation
- When a resident shows a significant overall decline
Last, Richard Russell, MBA, BSN, RN, CHPCA, president and CEO of Hospice of Northwest Ohio in Perrysburg, Ohio says to ask, “Would it be a surprise if this resident passes away in the next six months? If not, then staff may wish to consider a referral to hospice.”
Federal Requirements for Collaboration with Hospice
As with most issues in long-term care, there are federal regulations regarding a facility’s collaboration with a hospice organization. These regulations include such areas as notification of changes and maintaining a collaborative care plan. When reviewing how the facility collaborates with hospice organizations, facility leaders can refer to the following f-tags, along with the CMS Hospice and End of Life Care and Services Critical Element Pathway.
- F849 Hospice Services
- F637 Comprehensive Assessment after a Significant Change
- F656 Development/Implement Comprehensive Care Plans
- F657 Care Plan Timing and Revision
- F684 Quality of Care
- F745 Provision of Medically Related Social Services
- F841 Responsibilities of Medical Director
- F842 Resident Records: Identifiable Information
- F866 QAPI/QAA Data Collection and Monitoring
According to F849, the SNF must have a written agreement in place with the hospice organization prior to provision of services, and that written agreement must include:
- The services the hospice will provide and their role as managers of care
- The hospice’s responsibilities for determining the appropriate hospice plan of care
- The services the SNF will continue to provide
- A communication process, including how the communication will be documented between the SNF and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day.
F849 further states that the SNF must designate a point person with a clinical background who can coordinate the resident’s plan of care and act as a liaison between facility staff and hospice. Although it is not required by regulation, the written agreement should also stipulate billing practices.
Along with a written agreement, the facility should have in place policies and procedures regarding hospice care that include areas such as:
- When and how to refer a resident to hospice
- How facility staff should notify hospice of resident changes, including a significant change in status, change in plan of care, need to transfer the resident, or resident death
- The process for physician order changes
- How to request supplies and medications from hospice and what supplies can be requested
- How and when to report abuse, neglect, or mistreatment of a resident by hospice personnel
Collaborative care planning for a resident receiving hospice services is of utmost importance and a focus of surveyors when they are reviewing records. Unfortunately, this is where most SNFs miss the mark and receive citations related to care planning under F849, F656, or F657. According to F849, the collaborative care plan should include:
- Advanced directives
- Provision of activities of daily living (ADLs)
- Symptom management, including nausea control, agitation, pain, uncomfortable breathing, pressure ulcers, nutrition and hydration needs, and psychosocial needs
- Coordination of care with hospice and how to contact hospice 24 hours a day
F656 states that a comprehensive care plan should describe “the services that are to be furnished to attain or maintain the residents highest practicable physical, mental and psychosocial well-being.” F657 states that a comprehensive care plan must be developed within seven days of the completion of the comprehensive assessment, which includes a significant change MDS assessment. This care plan must also be reviewed and revised by the interdisciplinary team, which should include hospice representatives. Since the plan of care is intended to be a collaborative effort, facility staff should invite the hospice nurse or other hospice representatives to join the care plan meeting and share their expertise and understanding of the resident to formulate or revise a care plan. The facility should notify hospice of any changes to the plan of care, and vice versa, to ensure compliance.
F647 states that a significant change MDS assessment must be completed within 14 days when:
- A resident enrolls in a hospice program, or
- A resident changes hospice providers and remains in the facility, or
- A resident receiving hospice services discontinues those services.
The DNS should make sure there is a process in place to alert the facility’s MDS nurse of these events so that the facility meets these MDS requirements.
A resident on hospice can also affect the facility’s Quality Measures. If the MDS is coded that the resident is receiving hospice services, then the resident is excluded from the calculations for the following Quality Measures:
- Percent of residents who made improvements in function
- Percent of resident whose need for help with Activities of Daily Living has increased
- Percent of residents who lose too much weight
- Percent of residents whose ability to move independently worsened
- Percent of residents who used antianxiety or hypnotic medications
Barriers to Collaboration
Collaboration between organizations always has some impediments, and that between the SNF and hospice is no exception. The key to getting past these barriers is communication. There must be a culture of collaboration in both organizations. Cultivating this culture starts with education. Facility staff should initially be educated on topics such as:
- What hospice is and what services hospice provides
- What regulations need to be followed when collaborating with hospice
- What roles each entity plays
- When to refer a resident to hospice
- How to contact hospice
- Principles of death and dying
Additional education may be conducted as needed for areas such as pain management and advanced care planning.
Unfortunately, there are also a lot of myths surrounding hospice. Facility staff should also be educated regarding the following myths, so there is no confusion:
- A resident must be a Do Not Resuscitate (DNR) to receive hospice benefits – Residents’ code status does not prevent them from receiving hospice benefits, nor is a particular status required to initiate hospice care. However, there does need to be a conversation between hospice and the resident and family to clarify their wishes regarding resuscitation.
- A resident receiving hospice benefits cannot transfer to the hospital – A resident on hospice may transfer to the hospital after hospice evaluates them and agrees that the resident needs to be transferred. Remember that hospice is the manager of the resident’s care. The resident can also elect to drop the hospice benefit in order to transfer to the hospital and re-elect the benefit once they have returned to the facility.
- A resident receiving hospice benefits cannot receive therapy services – The resident’s plan of care drives all services. If functional ability can improve or be maintained through therapy services, hospice will agree to these services. Usually, these services are provided on a short-term basis and will be evaluated for need every few weeks.
- A resident receiving hospice benefits cannot have labs or x-rays – The resident’s plan of care drives all diagnostic tests. If the test will enhance care, then hospice will agree. Hospice frequently uses diagnostic tests to support the resident’s prognosis.
- The facility is penalized if a resident does not pass away within six months of electing hospice benefits – No one can determine when a person will pass. The burden of providing documentation to support the terminal diagnosis is hospice’s responsibility, not the facility’s.
- Hospice speeds up a resident’s death – Hospice care neither hastens nor prolongs the dying process. It does, however, make the resident as comfortable as possible during the process and improves the quality of life.
For additional information on hospice collaboration, along with a checklist of what should be in place for a resident receiving hospice benefits, please refer to AAPACN’s Hospice Collaboration Toolkit.
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