Tool decides who would benefit from CNA visits

Client satisfaction improves with its use

Hospice families often need assistance with personal care for their dying loved one, but it's sometimes difficult for hospice staff to determine which patients truly need the help and which would be just as well off without it.

"Is it the staff determining that the patient and family have this need, or is it a need that the patient and family have identified," says Lorna Hearn, RN, BSN, MS, vice president and chief operating officer for Delaware Hospice in Wilmington.

"Many times we have found in retrospect that our staff offer personal care services to every patient and family because every patient is seriously ill," she says. "Then the certified nursing assistant [CNA] arrives in the home to find that personal care has already been accomplished."

Providing CNA care to almost every patient is difficult in light of financial and staffing constraints, Hearn notes.

"So, we said we needed to get a handle on this," she says.

CNA education

As a result of a quality improvement process that involved making CNA visits more efficient, the hospice developed an assessment tool, new policies, and training program. The result was that the hospice's costs decreased by 20%, while caregiver satisfaction increased, Hearn says.

"We actually decreased by only a small percentage the number of visits per week per patient," she says.

The big change was that nursing assistants may visit patients for less than the two-hour visit, which was standard before, and their visits are supplemented with volunteer visits, Hearn says.

This way nursing assistants can go into a home where the assessment determined a need, provide the necessary services, and leave to make the next visit. Then, in cases where CNAs previously would also provide some respite care for families, staying with patients while a caregiver ran an errand, now these sorts of visits are scheduled in advance with hospice volunteers, Hearn explains.

Here's how the new program works:

1. Develop a CNA assessment tool.

Delaware Hospice's home health aide assessment tool provides evaluative scoring in three major areas:

Patient's actual condition: This includes the patient's ability to assist with care and transfer out of bed and bear weight, and the patient's comprehension and cooperation and orientation to reality.

Activities of daily living (ADLs): "We go through the standard list of ADLs, and they're scored depending on how many ADLs they need assistance with," Hearn reports.

Caregiver's abilities: "Is the caregiver able and willing to provide care?" she says. "The caregiver may be able, but not willing, or the caregiver might be working full time or is an adult son caring for his mother, and he's really uncomfortable with personal care."

At admission, nurses evaluate the patient and family, using the assessment tool, and they will use the tool again whenever there's a changing need with the patient, Hearn says.

2. Decide assessment scoring.

The hospice's assessment tool provides scoring in this way:

For CNA visits twice a week: The patient is dependent on at least two ADLs and has a score of two in the patient's condition. The higher the number means the patient is worse off physically.

For CNA visits three times a week: The patient would need to have a score of three or higher, and the patient would need to be dependent on at least three ADLs or have moderate disease progression, having some occasional confusion or agitation, and either having no willing or able caregiver or having a need for ostomy care, catheter care, or nonsterile dressing change.

For CNA visits five times a week: Four of the following conditions must be present: the patient is dependent in four out of five ADLs, the patient's condition is a four or five score; the patient has rapid disease progression, is actively dying, or is comatose; the patient is bed-bound; there is no willing or able caregiver; and the patient has ostomy, catheter care, or nonsterile dressing change needs.

For CNA visits seven times a week: All of the following would be true: the patient is dependent in all ADLs; the patient's condition is a six to eight score; the patient is bed-bound; there is no able caregiver, or the caregiver is exhausted; the patient is dying or comatose; the patient has multiple symptoms not in control, and the patient has either ostomy or catheter care or needs nonsterile dressing changes.

For two CNA visits per day, five days per week: Three of the following four conditions must be met: the patient is dependent in all ADLs; the patient is bed-bound; there is no able caregiver; there are excessive symptoms, such as diarrhea, vomiting, bleeding, heavy drainage; or there's another crisis going on in the home.

For there to be two CNAs assigned to each visit: There must be three of the following conditions: the patient is dependent in all ADLs; the patient weighs more than 250 pounds; there are staff safety issues; the patient is bed-bound; and there is no able caregiver.

3. Have CNAs teach caregivers how to provide care.

"As a part of this whole initiative, we had our CNAs teach caregivers more about how to provide the care," Hearn says. "We built into the tool the ability to determine whether caregivers needed some education."

Hospice nurses taught CNAs what to teach family caregivers, and so some of the CNA's visit time is spent providing this education, she explains.

"My goal was that we would reduce our cost and use the resources we had available without affecting the quality of care negatively," Hearn says. "So the goal was that caregiver satisfaction would stay the same, but in fact what happened is it improved."

Previously, CNAs never had the responsibility to teach caregivers, but as part of the project there was a training module about ADLs added to the CNA training, she notes.

"We teach them how to teach others to give a bath, how to transfer a patient out of bed into a wheelchair or commode, how to change bed linens with the patient in it, and some of the other specific tasks required to provide personal care," Hearn says. "We take it for granted that everyone knows how to do these tasks, but for many people they've never had to bathe anyone except small children, and this is a whole different set of skills."

She says the CNA education probably has contributed to the increase in caregiver satisfaction. For example, one question included in the caregiver survey asks, "How confident did you feel about doing what you needed to do in taking care of the patient?" she explains.

"And the percentage who answered ‘very confident' rose from 72% to 74%," Hearn says. "So we felt confident that the initiatives we had put in place were continuing to help us provide quality services."

CNAs also report being happier with their jobs and feeling more valued as a member of the hospice team now that they have the added responsibility of education and since they make more efficient visits, she says.

"CNAs tell us that even though they are doing more visits a day, they feel much happier because they feel useful," Hearn says. "Instead of going to a patient's home where the bath already has been given, they're going into a home where they're truly needed and have an opportunity to do some teaching."

4. Improve use of volunteers.

The hospice has changed the way volunteers are used and how CNA services are presented to patients and caregivers, Hearn says.

"We say, ‘We'll have the CNA do personal care and stay long enough to do so, and if there is time you need to be relieved, we'll have volunteer services help you with that,'" she says.

This way respite care is removed from CNA services and becomes part of the hospice volunteer support that's provided, Hearn explains.

"Our use of patient/family volunteer services has increased as a result of the project," she says. "Part of the challenge is making good use of those resources as well."

Need More Information?

  • Lorna Hearn, RN, BSN, MS, Vice President and Chief Operating Officer, Delaware Hospice, 3515 Silverside Road, Wilmington, DE 19810. Telephone: (302) 479-2577.