Take proactive steps with a potential hospice case
Benefits change in end-of-life situations
If you’re a case manager, you’re likely to encounter end-of-life situations no matter where you work, B.K. Kizziar asserts.
"Almost all case managers end up dealing with end-of-life situations. It’s hard to get away from it. Even case managers in a rehab setting are dealing with cancer patients referred for treatment because they are debilitated," says Kizziar, RNC, CCM, CLCP, case management consultant, life care planner, and owner of B.K. & Associates of Southlake, TX.
Hospice case management is approached in a different way from other case management, Kizziar says. "Hospice case management is somewhat broader in scope while being more focused, as contrary as that sounds. There is more implication for family and significant others to be involved preparing for a loss, which is quite different from fighting to survive," she says.
Even in end-of-life situations, case managers and providers need to do as much ongoing negotiation as in cases where the patient is expected to recover, Kizziar says.
But the providers usually are different. Case managers aren’t negotiating to have providers treat the patient aggressively. Usually, they deal with taking conservative measures and finding respite for the family members so the family can be involved at a level that is comfortable for them, she says.
In the transition period between acute care and hospice care, the case manager must have acute foresight. They have to know, through a close relationship with the family and physician, when the tide starts to turn toward a hospice situation.
Once a physician says that the patient can be expected to live six months or less, the case goes into the hospice mode, Kizziar says.
There are a lot of different hospice environments — inpatient, outpatient, home, and day programs. Case managers need to determine what is available through a payer source and what is not.
Case managers should keep a close eye, because benefits will change if it becomes a hospice situation. For instance, hospice care may cover pain management but not personal care.
"With private insurance, many times there are opportunities to negotiate some pieces of hospice care and to take some of the financial burden off the family," Kizziar says.
For instance, personal care may not be covered, but the payer will cover the intravenous pain medicine through home health care. If the patient does not have hospice benefits, there may be issues of medical necessity, treatment, or palliative measures.
"Look ahead to the transition. Find out what is or isn’t covered. Look at community resources and meet with the family to find out what they are able to pay for," Kizziar suggests.
If the family chooses to assume the care so the patient can be at home, teach a family member to care for the patient’s needs.
Commercial payers do not cover many types of hospice care. "There is almost always a limit to what a payer calls hospice.’ It is a matter of budgeting the hospice allotment and providing the other things the patient and family need through community resources," Kizziar says.
Research and prepare early
Case managers should start researching these possibilities early on and helping the family prepare for what happens later.
"In end-of-life situations, we see more family caregivers and privately hired caregivers that payers don’t cover," Kizziar says.
Long-term care insurance usually has a hospice rider that will cover anything from having a neighbor come over and give the family relief to home health care by a licensed provider.
Social workers are a valuable addition to a hospice care team because they are familiar with what is available in the community at little or no cost to the family, she adds.
If payer case managers believe a case will become a hospice situation, they should communicate with the physician to make sure they are the first to know. "Many times, if the family or patients are in denial, even though it is clearly an end-of-life situation, the physician won’t classify it as a hospice case. In these cases, aggressive care is being provided even through the end of life," Kizziar says.
It is appropriate for case managers to approach the physician to ask if it is going to be a hospice-appropriate case and where they are in their discussions with the family about the prognosis.
Case managers can approach the physician, but neither the case manager for the payer nor the provider can force the physician to declare a patient terminally ill.
A case manager’s relations to the family is critical in any case, but even more so in end-of-life situations, Kizziar adds.
"Case managers need to prepare the family for what happens afterwards. We often forget that part because we are too busy focusing on what is happening today," Kizziar says.
When you deal with people who are in a terminal situation, you have to be upfront about death and dying. Communication with the family and the patient is one of a case manager’s most important roles, she says.
Case managers must tread a fine line to determine how the family members are dealing with their feelings, Kizziar points out. Some people simply are not ready to discuss the future. Others insist on being the sole caregiver for their loved ones. She suggests gathering written material on coping and leaving it with the family. Find out their spiritual preference and get in touch with the appropriate people. "It’s important for any case manager working with a hospice case to know the family’s spiritual needs and see that they are addressed as well."
Organizations such as the Kidney Foundation and the American Cancer Society have wonderful resources on death and dying. Refer family members to support groups.
"I refer all my clients to some kind of support group," Kizziar says.
However, she points out, you have to be aware that some people are going dig in their heels; then you have to lay off.
"When I went to nursing school, we were told that we shouldn’t get involved. But there is an appropriate way to be involved. There is nothing wrong with caring and having empathy without getting drawn up into it," she says.
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