Decrease hospice denial rates through documentation education

Hospice shows how to support limited prognosis

A Pennsylvania hospice reduced its denial rate by more than 80 percent after instituting a formal educational program that taught staff how to properly document patients' need for hospice care.

"We realized we weren't painting the picture as we see it," says Janet Carroll, MSN, CHPN, vice president of clinical services for Hospice of Lancaster County in Lancaster, PA. Carroll also is the chair of the National Hospice & Palliative Care Organization's (NHPCO's) regulatory subcommittee.

"To say a patient is weak does not paint the picture," Carroll says. "We have to say what it is about this person's weakness."

The hospice focused staff training on how to support the gut feelings they had about patient's prognosis, she explains.

"Hospice eligibility is determined by limited prognosis," Carroll says.

"What we were able to do with our own staff and what we're sharing with others in the industry is that perspective," Carroll says. "And the other piece of our documentation is how one supports the level of care."

A hospice patient's symptoms will improve by virtue of the fact that the hospice team is providing symptom management and support, but symptom relief does not necessarily change the prognosis, Carroll explains.

When assessing patients, hospice staff should compare them to well patients, not to dying patients, and they should explain why there has been an improvement if there is any improvement in symptoms.

This is why thorough documentation is necessary, Carroll says.

Hospice of Lancaster County held 1.5-hour workshops on documentation, attended by groups of eight to 12 employees, Carroll says.

The workshops covered the critical times, including admission, course of care and change of level, and recertification, she says.

The staff education also explained to employees that all hospice notes must do the following:

  • paint the picture in words;
  • be written for someone who does not know the patient;
  • support the prognosis.

Also, the staff is taught that the visit note requires staff to do the following:

  • begin the note before the visit;
  • anticipate: know what you are going to look for before you walk through the door and achieve balance;
  • know what you will need to document;
  • know what the patient and family need today.

The visit note should include the following:

  • patient and caregiver report;
  • physical assessment with details beyond "weakness, pain, and shortness of breath"
  • disease-related signs, symptoms, changes, including wounds;
  • function: activities of daily living, compliance;
  • nutrition: weight, intake, change in diet;
  • emotional health: coping, caregiving, family dynamics;
  • spiritual health, including coping, meaning, faith, spiritual support;
  • other changes and other needs;
  • nursing and certified nursing assistants assessments; and
  • physician assessment and orders.

Hospice staff should continually ask themselves the question, "What did I see, what are we monitoring?" Carroll says.

For example, if a hospice nurse documents that a patient has no nausea when there was a problem with nausea before, then that gives an incomplete report. The truth that should be documented might be that the patient is receiving medication for nausea every six hours around the clock to control the symptom, Carroll says.

"If you say there's a decrease in the patient's activity, what does that mean?" Carroll says.

It would be better to document that the patient used to walk up and down the stairs, but now can only get out of bed to go to the bedside commode, she explains.

"In terms of whether a patient appears weaker, tell me what that means," Carroll says. "If I ask the person who makes the assessment where did you get the idea the patient was weaker, the person might say, 'Last week the patient greeted me at the door, and we walked out into the backyard, and this week the patient greeted me at the door, but barely made it to the couch in the living room.'"

But if the hospice nurse doesn't document both examples of the patient's activity then there is no reference point for comparison, showing how the patient has become weaker, Carroll says.

Even saying the patient appears more uncomfortable is not sufficient documentation.

What might be said instead is that the patient last week was able to sit in a chair, move around easily, and now he is guarding his right side and his breathing is shallower because of increased pain, she says.

In another example, it could be that a patient who used to be short of breath when greeting the nurse at the door now is breathing normally when opening the door. While this might appear to be an improvement, the truth might be the more complex answer that the patient had been walking down the stairs before opening the door, and now the patient's breathing has become so difficult that the patient doesn't take the stairs at all anymore, Carroll notes.

"That's a case where it may appear things have improved, but it's because the patient has accommodated," she explains. "So the patient may be less short of breath, but it's because the patient has become less active."

Key points to remember when documenting hospice notes are to not confuse the word decline with prognosis, or to think that an improvement in symptoms means an improvement in prognosis, Carroll says.

By including all of these details in documentation, the hospice employee is providing a clear picture that essentially shows how the intervention is working, but it doesn't mean the reason for pain or shortness of breath has gone, Carroll says.

Hospice eligibility uses the time frame of six months prognosis, but the benefit is unlimited as long as at each point of recertification someone is still saying that if the patient's disease runs its normal course the patient will die within six months, Carroll says.

"If a patient has a limited prognosis then the patient should be recertified for hospice care, and we should paint the picture of why we think that," Carroll says. "We need to translate our gut feeling into something that would convince someone else as to why we think this is the situation."

Need More Information?

  • Janet Carroll, MSN, CHPN, Vice President of Clinical Services, Hospice of Lancaster County, 685 Good Drive, P.O. Box 4125, Lancaster, PA 17604-4125.