Lack of education hindering NH referrals
Conflicting policies culprit of lost opportunities
Elderly men and women living out their final weeks or days in nursing homes often die in pain and without the solace of spiritual care. They sometimes endure unnecessary interventions that prolong their suffering and are not allowed the peaceful death they deserve.
That is the hospice perspective. The nursing home perspective, however, is oftentimes quite different. Those differences, no matter how small, can result in a chasm so deep that a nursing home and hospice are unable to mend it.
Experts from both disciplines say each side needs healthy doses of education about the other’s mission and practices to increase understanding and foster cooperative work arrangements. "There is a fear factor," says Christine Johnson, RN, MS, executive director of The Inn at Barton Creek, an assisted living facility in Bountiful, UT. "For that reason, I’m not sure we’re [working together] as well as we should be."
For hospices, nursing homes represent an underutilized referral source. It is common for nursing home staff to think that hospice care in their nursing homes is a duplication of effort, but they are often unaware of the psychological, social, religious, and cultural programs that can benefit their patient.
A daunting requirement
Current federal regulations and recent Office of the Inspector General reports singling out hospice and nursing home relationships have raised the barrier that prevents more hospice/nursing home arrangements. (See related story, p. 20.) The most daunting of them is the six-months-or-less diagnosis requirement for hospice admission. With Medicare officials looking more closely at that requirement, hospices are hesitant to assume the risk of caring for nursing home patients. On the other hand, the difficulty in making such a diagnosis prevents nursing homes from making a timely referral or calling in hospice at all.
Despite regulatory barriers, some nursing homes and hospices manage to work out arrangements that are clear of regulatory missteps and benefit both organizations. A study published in the journal Gerontology estimated 13,369 Medicare hospice beneficiaries reside in Medicare/Medicaid-certified facilities on any given day. For the most part, hospice beneficiaries are being served in nursing homes that do not have specialized hospice units because only about 1.3% of nursing homes have such units. Nursing homes with higher percentages of residents receiving the hospice benefit are more likely to be for-profit, belong to a chain, and not provide full-time physician coverage. The proportion of residents receiving the hospice benefit increased in counties with fewer certified nursing home beds and areas with more certified hospices, for-profit hospices, or larger hospices.1
So why are only a few successful while other seemingly compatible organizations struggle to work together?
The answer, says Johnson, lies more in the lack of understanding nursing homes have of hospice care and vice versa than it does with regulatory barriers.
"It’s the lack of understanding that creates lost opportunities," Johnson says. "Little miscommunications can cause huge chasms that can lead to a nursing home not wanting to go through the trouble of bringing in a hospice again."
Rewriting the rules
Johnson speaks not just as a nursing home administrator, but also as an expert in nursing home-hospice relationships. In 1997, after a number of nursing homes in Utah complained that there seemed to be an unusual push for hospice services in nursing homes, she cowrote the Utah Health Care Association’s guidelines for delivering hospice care in a nursing facility. A committee of nursing home and hospice officials edited the text.
The challenge, says Johnson, is for the two disciplines to coordinate care, while reconciling differences in policies and procedures. For example, nursing homes operate under strict assessment schedules that are tied into reimbursement, while hospices are not. Even though a nursing home resident is under the care of hospice, the nursing home is still responsible for submitting routine patient assessments, called the Minimum Data Set (MDS). Because hospice staff are not experienced in using the MDS, proper filing is difficult, Johnson says.
Nursing homes just don’t understand hospices, says Patricia Whitney, director of hospice at St. Margaret’s Hospital in Spring Valley, IL. Last September, Whitney wrote an article in Provider magazine, the trade publication of the National Health Care Association, the largest nursing home trade organization in the country. In it, she described the benefits of hospice and described the clinical signs nursing homes can use to make appropriate and timely referrals of their Alzheimer’s disease patients to hospice.
Educating nursing homes about hospice care is the key to developing steady referrals to hospice, she says. "The goal is to get them to call us," Whitney adds. "Right now, it’s mostly by chance. A patient or patient’s family hears about hospice and asks the nursing home to bring us in."
From Whitney’s perspective, nursing home staff are not trained in palliative care and don’t understand hospices’ intentions to treat pain proactively, before it becomes unbearable. "We keep patients from bouncing from the nursing home to the emergency room because we keep their pain under control."
Further, hospices do try to educate nursing home staff, she says, but the message is short-lived because of the high turnover among nurses and aides in nursing homes.
Mending chasms
Neither Whitney nor Johnson are pointing fingers, though. Each agrees that there is enough blame to go around. For starters, Whitney says no one can blame the lack of knowledge about hospice care on any one else other than hospices themselves. They are missing opportunities to educate nursing home staff, she says.
In addition to regular inservice training, hospice workers need to have an ongoing training component. For example:
• Bring written literature about your hospice and its mission to the nursing home when visiting a patient to help educate new nursing home employees who have not yet participated in hospice inservice training.
• Invite nursing home staff to your hospice’s hospital inservice training.
• Make your palliative care services available to nursing homes. Even though a hospice cannot receive payment unless the patient has a terminal illness diagnosis, Whitney says this is excellent goodwill, which will lead to future referrals.
For their part, hospices need education of their own. Nursing home staff are often frustrated by hospice staffs’ seemingly cavalier attitude toward nursing home policies. For instance, Johnson says hospices sometimes do not appreciate the strict schedule of patient assessments that are required by Medicare. The MDS, a lengthy patient assessment form, must be completed every 30 days for the first 90 days of care and every 60 days after that. Even though the hospice has clinical management of the patient, the nursing home must still complete the MDS because the patient is still a resident of the nursing home. Because hospice is providing a significant portion of the care, their input and assistance is needed to complete the assessment.
"Hospices don’t have the same requirement, so they don’t place the same amount of importance on getting these assessments done as a nursing home," Johnson says. "They need to become aware of the MDS as a nursing home tool."
A tale of conflicts
Johnson identified 10 key areas in which nursing homes and hospices can become entangled in conflicting policies and regulations:
1. Coordination of billing. The two organizations need to work out who is going to bill for what services. This includes understanding the responsibilities of clinical management of the patient and distinguishing between routine care provided by nursing home staff.
2. Patient self-determination and advanced directives. Both organizations are responsible for ensuring the patient’s rights to informed consent are being respected. To ensure the patient’s wishes are being carried out, nursing homes are required to inform patients of their right to formulate an advanced directive that establishes special power of attorney, a living will, and a medical treatment plan. For the hospice’s part, it should ensure that an informed consent form that specifies the type of services that could be provided by the hospice is obtained for each patient.
3. Resident assessment. As mentioned earlier, hospices must cooperate with nursing home staff to ensure timely completion of the MDS, either by agreeing to complete the form based on its working knowledge of the patient or provide the needed information to nursing home staff responsible for completing the MDS.
4. Comprehensive care plans. While both hospices and nursing homes have care plans, they come with different requirements. For example, nursing homes are required to review and update their care plans every 30 days for skilled-nursing patients and quarterly for long-term care patients. Hospices do not have the same requirement. The result can be two care plans for one patient evolving in two very different ways. Both organizations must strive to coordinate their care plans so that they account for each other’s goals and are updated at the same time. "Work toward mutual support and understanding," Johnson says.
5. Professional communication. In order to facilitate the coordination of care plans, there needs to be standard mechanisms in place to notify each provider of changes in the care plan or changes in the patient’s condition. Johnson suggests each organization designate a staff member as the person to call when changes are made and to coordinate how the changes will be handled. For example, a hospice might designate the on-call nurse as the liaison so that nursing home is assured of reaching a nurse who is able to make sure changes are noted and care is provided in a timely manner.
6. Interdisciplinary team. Both nursing homes and hospices use a variety of disciplines to treat their patients. Each organization depends on the interaction of these disciplines to help determine the best course of care. When a hospice comes into a nursing home, the need to recount observations and communicate changes in care does not diminish. There is a need for both interdisciplinary teams to work together. Johnson suggests that each organization include a representative from the other’s team to act as a liaison between the two groups.
7. Physician services and visits. Hospices need to educate nursing homes that an essential component of hospice is physician-directed interdisciplinary care. The nursing home physician must clarify his or her role with hospice, including whether he or the hospice medical director will certify the care plan and services to be given.
8. Medications. This area is one with the greatest potential for conflict. Nursing homes must follow specific regulations for certain drugs, such as psychotropic and anti-psychotic drugs. Before nursing homes can use them, there must be a specific diagnosis, such as depression or mental illness. Hospices, on the other hand use some of these drugs routinely as part of its pain management arsenal. A conflict can arise when a hospice has placed a resident on one of those drugs to manage pain, but a nursing home nurse refuses to administer the drug because the patient doesn’t have the required diagnosis. If the nursing home nurse would have been properly educated about the hospice’s pain management plan and told why the drug in question was being used, the patient would have been forced to suffer needlessly, while the two sides straightened out their differences.
9. Clinical records. When a hospice comes in to treat a nursing home resident, it must establish a patient record. But that record also represents care delivered while the patient is a resident of the nursing home. Nursing homes and hospices must agree on how they will share their records, including which organizations keeps the original copy.
10. Nursing home staff training. Hospices need to establish a collaborative training program with their nursing home partners. Hospices often treat facility staff training as a work in progress, says Johnson. In order for training to take root, hospices must make sure nursing home administration is taking part. With high-level management participation, there is greater likelihood the concepts taught will remain with the organization despite the high turnover rate of nurse and aides.
Getting nursing homes to make regular referrals will be an arduous process for hospices. There are deep-rooted territorial issues to overcome on top of misperceptions of hospice care. Yet, that doesn’t change the fact that there are nursing home residents who are dying and need the comfort of hospice care, says Whitney.
"If you have a nursing home that knows hospice, it can be a good relationship," she adds.
Reference
1. Petrisek AC, Mor V. Hospice in nursing homes: A facility-level analysis of the distribution of hospice beneficiaries. Gerontologist 1999; 39:279-290.
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