Eli's Hospice Insider

Your patients are trained to call 911 in an emergency -- it's your challenge to help them break this habit.

When the Centers for Medicare & Medicaid Services takes an interest in revocations, it's time for hospice providers to do the same. Fortunately, with a few proactive steps, you can reduce the number of patients who revoke hospice service due to unplanned hospitalizations with non-contracted facilities.

Out of pocket: When a hospice patient receives care related to the terminal diagnosis at a non-contracted hospital, he should exercise his option to revoke his hospice benefit or he could wind up  footing the bill. Or, in an effort to prevent alienating a patient, many hospices opt to pick up the bill themselves.

"Hospice care asks patients to consume healthcare in a way that is completely different from what they are accustomed to in this country," says Susan Balfour, RN with Hospice Fundamentals. "Most other healthcare doesn't ask you to call your provider first. We're saying 'If you think it's an emergency, call us first.'"

It's not always possible to avoid these unplanned hospitalizations, but you can minimize the number of patients who make this decision with these tactics.

To help prevent unplanned hospitalizations in non-contracted facilities,

Balfour suggests the following steps:

• During the election of benefit process, provide a list of contracted hospitals.

• Review the list of contracted hospitals with the patient and family.

Identify whether they use another hospital and plan to use that hospital in the future. Can you get a contract with that hospital?

• Leave a revocation statement with the patient and family and explain how to use it.

"If the patient chooses to go to a non-contracted hospital for some reason and can't or won't call you first, there is no reason they can't complete that revocation statement right then," Balfour said during her recent Eli-sponsored audioconference "Revocations, Discharges, & Transfers: Handle with Care"

Another proactive step you can take is to identify up front situations that may give rise to unplanned hospital admissions or ER visits, Balfour says. Then you can work to minimize them. Some items to be on the look out for include:

• Patients with a history of frequent ER visits and hospitalizations.

These patients have been trained to call 911 and head off to the hospital, Balfour says.

• Symptom crises. Patients and family experience increased anxiety during these times and may panic.

• Arrival of out-of-town family members. Visitors who haven't seen the patient in a long time may be taken by surprise and feel the need for emergency care.

"Patients and family are more likely to panic when they are new to hospice service, so we try to make more visits and calls in those early days to make sure they are settled in," says Samira Beckwith with Hope Hospice and Community Services in Ft. Myers, Fla.

"You may tell a patient and his family at the time of admission not to call 911 in an emergency, but you're giving them all sorts of other information at that time, too," Balfour says. The likelihood of them remembering all of this information is slim. It is important to re-review the material as care continues and make sure that you are not talking in "hospice/Medicare code" -- language that makes sense to hospice staff, but not to anyone else, Balfour says.

"The key to preventing revocations is having an excellent initial assessment with the patient and family," says Lynda Laff, RN, BSN, COS-C with Laff Associates in Hilton Head Island, S.C. "Often revocations are due to patients and/or family members not really understanding hospice care."

Unplanned hospitalizations can arise frequently with certain types of patients such as chronic lung disease patients who are often frequent travelers to the emergency room, Balfour says. Consider what you can do in your care planning to head this off. Perhaps start a daily 7:00 pm call, increase your visits, or provide weekend visits if you see a potential problem.

When a patient has a symptom crisis, adding in an evening call to check on them and another call the following morning to see how things are going and to assess the situation can make a difference, Balfour says.

Consider sending your social worker for an extra visit to assess the situation and address any anxiety.

Another tip: Have a staff member on hand when an out-of-town relative arrives to help ease any worry they may have, Balfour suggests.

While you may not be able to prevent all unplanned hospitalizations, the following educational efforts may help you to reduce them.

• Create an instruction sheet the patient can hang up on their refrigerator or near their phone with instructions in case of an emergency. Include your on-call instructions as well as directions for what the patient should do. For example, "Don't call 911, call us." However, if that sheet includes wording such as "If you haven't heard back from us in 30 minutes, call us again," ask yourself how likely it is that will follow the instructions when they perceive they are in an emergency situation, cautions Balfour.

• We give our patients a "Hope Hospice" card to show when they go for any kind of treatment," says Beckwith. The card explains that its carrier is a hospice patient, gives the 24 hour call-in number, and asks the provider to call. Patients are used to showing a Medicare card, so this works well, Beckwith says.

• Have regular educational sessions with 911 staff, Beckwith suggests.