10 areas require particular attention
While better cooperation among hospices and nursing homes will result in better end-of-life patient care, there are snares and traps awaiting any cooperative effort. Here are 10 areas where nursing homes and hospices can become entangled in conflicting policies and regulations:
1. Coordination of billing. The organizations need to decide who will bill for which services. This includes understanding the responsibilities of clinical management of the patient and distinguishing routine care provided by nursing home staff.
2. Patient self-determination and advance 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 advance 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 specifying the type of services that could be provided by the hospice is obtained for each patient.
3. Resident assessment. Hospices must cooperate with nursing home staff to ensure timely completion of the Minimum Data Set (MDS), either by agreeing to complete the form based on a working knowledge of the patient or by providing 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.
5. Professional communication. To facilitate coordination of care plans, standard mechanisms should be 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 the 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 teach nursing homes that physician-directed interdisciplinary care is an essential component of hospice. The nursing home physician must clarify his or her role with hospice, including whether that physician or the hospice medical director will certify the care plan and services to be provided.
8. Medications. This area has 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 their pain management arsenals. A conflict can arise when a hospice has placed a resident on one of these 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 not 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 organization 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. For training to take root, hospices must make sure nursing home administration is taking part. With high-level management participation, there is a greater likelihood that the concepts taught will remain with the organization, despite the high turnover rate of nurses and aides.
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