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Eli's Hospice Insider

Coordination Of Care:

Develop a 'Win-Win' Situation With Nursing Homes to Ensure Top-Notch Outcomes

Published on Fri Jan 16, 2009

4 strategies can help you -- and the nursing home -- get on the same page.

Talk about a potential dilemma: Providing hospice services in a nursing home requires you to partner with facility staff who may fear a hospice patient's decline or palliative care will get them in hot water with surveyors. But the hospice interim final interpretive guidance stresses coordination of care between hospice and nursing homes like never before.

Solution: This four-pronged approach will help your hospice get in synch with nursing facilities.

Strategy No. 1: Know How to Coordinate the Care Plan

The new Conditions of Participation (CoPs) talk about nursing homes and hospice having one care plan, notes Cherry Meier, RN, MSN, with VITAS Innovative Hospice Care in Flat Rock, N.C. As many in the industry had hoped, however, the January 2009 interim final interpretive guidance clarifies that the hospice and nursing home can divide the coordinated care plan into two parts. "CMS folks expect the hospice plan of care to relate to the terminal illness " and the nursing home plan of care to relate to every other part of care provided to the resident," says Judi Lund Person, with the National Hospice & Palliative Care Organization.

"The two plans should reflect each other ...," counsels Beth Carpenter, president of Beth Carpenter & Associates in Lake Barrington, Ill. "This isn't new," she adds. But the hospice CoPs make that more clear than previous terminology that "connoted to some extent that the two didn't step on each other's toes."

More than a paper exercise: "When the care plans don't coincide, it probably leads to poor care," cautioned Harold Bob, CMD, MD, a nursing home and hospice medical director, in a presentation on palliative care and survey regulations at the 2008 American Medical Directors Association annual meeting.

Do the side-by-side test: Lay the nursing home and hospice care plans side by side to make sure they seem like the same patient, experts advise.

Strategy No. 2: Help the Nursing Home Develop Palliative Solutions

Set the tone for promoting a unified approach and palliative care from the get-go. For example, Meier advises a hospice nurse caring for patients in nursing homes to make the facility's minimum data set (MDS) coordinator her "very best friend." The hospice nurse can review the MDS and the problems triggered for care planning. Then the nurse should compare those to the problems identified by the hos-

pice assessment, and discuss these with the MDS coordinator, Meier says. The "hospice nurse can then help the MDS team with the care plan and work on finding palliative care solutions to the patient's problems."

Focus on these key areas: Nursing homes tend to differ from hospice in how they address weight loss, pressure ulcers, and pain, notes Meier. Thus, make sure nursing home staff knows to give patients their PRN medication for break-through pain, and to report instances where the patient seems to be requiring more PRNs than usual.

Strategy No. 3: Develop Standard. 2-Way Communication Systems.

The hospice staff should collaborate with the nursing department to provide their assessment information for the MDS, including pain, says Gail Robison, RN, RAC-CT, a consultant with Boyer & Associates in Brookfield, Wis. That strategy will improve the accuracy of care plans, as well as nursing home pain quality measures, which help the nursing home spot inadequate pain management efforts. "The hospice staff should also communicate to the nursing staff any changes they've observed in the patient," Robison says. Ditto for the hospice, adds Carpenter.

Tip: Make sure the nursing home knows to notify the hospice if it plans to send the person to the hospital or if the patient dies.

Strategy No. 4: Identify, Address Nursing Home Staff Concerns

In some cases, your hospice team may also have to educate or work with nursing home staff to allay their survey or care concerns.

This may help: The CoPs and interim final interpretive guidance requires the hospice to give the nursing facility a copy of the patient's hospice election, and the physician's initial and subsequent certifications of the terminal illness, Meier says. And nursing home staff members can show surveyors these documents if they express concern about a hospice resident receiving certain types of care -- or whether someone is terminally ill.

Look for this: Sometimes nursing homes may balk at the hospice's palliative approach due to their own grief reaction, observes Meier. "It can be hard for the staff to let the dying resident go sometimes," which is a sign of compassionate care, she adds. And hospice can come in "and help staff cope and let go."

Provide a reality check, if needed: If all else fails, you might give a particular facility or staff member(s) a heads up that nursing home surveyors are getting more with the hospice philosophy for end-of-life care.

NHPCO's Person says the word is that surveyors on both sides are looking for communication and coordination of care between the two providers related to the plan of care, documentation, and communication about changes in the patient's condition.

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