Are you taking advantage of nursing home opportunities?

Establish good relationships with open communication

Of the 1.4 million Americans receiving hospice care, 319,200 reside in nursing homes. It is encouraging that nursing home patients are electing the hospice benefit, but it also is discouraging that only 6% of the total nursing home population in the United States chooses hospice care, even though 1 in 4 deaths occurs in a nursing home.1

A nursing home and hospice relationship can be a win-win situation, says Samira Beckwith, president and CEO of Hope HealthCare Services in Fort Meyers, FL. "The hospice provides additional resources for the nursing home's patients who require a higher level of care," she says.

Hospice care reduces the number of transfers to the emergency department or the hospital for symptom control, and keeping the patients in the nursing home protects the nursing home's reimbursement, she explains. "The expertise of the hospice staff also provides better pain and symptom control for nursing home patients so the patients and their families are more satisfied with their care," Beckwith adds.

With 50% of her hospice patients residing in nursing homes, Linda Todd, RN, executive director of Hospice of Siouxland in Sioux City, IA, knows the challenges and steps to success with nursing home relationships. "We have developed very good relationships with the nursing homes in our area, but these relationships have evolved over time," she reports. As the relationships developed, nursing home staff members were more open to hospice care for their residents and they understood the benefits, Todd says. "It also takes time for our hospice staff members to recognize the special needs of nursing home patients that differ from hospice patients who are in their own homes," she adds.

"Nursing home hospice patients most often have family members who live in other areas, so our staff is communicating long distance with them, rather than face-to-face as they do in the private home," Todd explains. "This requires more time to be sure that family members understand hospice services and are reassured that their family member is receiving the best end-of-life care possible."

Although family members might not be close by, the nursing home staff develops long-term, close relationships with the nursing home patient, so they also must be reassured, says Martha Barton, RN, CEO of Pikes Peak Hospice and Palliative Care in Boulder, CO. "As in all areas of health care, there are 'turf wars' when hospice first provides care in a nursing home, but we understand that it is difficult to run a nursing home, then have someone else come in to change the care provided to a patient," Barton says. "We also have to remember that there is a personal connection between the nursing home staff and the patients."

Pikes Peak has been working with nursing homes since 1990 and has developed some strong relationships, says Barton. One of the keys to success with nursing homes is constant education, she says.

"We take every opportunity to provide inservice education to nursing home staff," Barton says. Topics range from clinical issues such as symptom management to bereavement counseling, she says.

When planning staff education, don't forget to address regulatory issues such as the difference between regulatory requirements for nursing homes vs. hospices, "It's important that the nursing home staff members understand that we are required to provide services and documentation that they may not be required to provide, so that they can understand why we do some things differently," Barton says.

Communication and consistency of staff are two other ways to build strong relationships with nursing homes, suggests Bridget Montana, MS, APRN, MBA, chief operating officer for Hospice of the Western Reserve in Cleveland.

"We have 10 teams that are dedicated to nursing homes and assisted living facilities," she says. The dedicated staff makes education and training more effective because nursing home patients have unique needs, Montan reports. "The basic needs of hospice patients in the nursing home are the same as patients in their own home, but the staff working in the nursing home needs to understand the nursing home environment," Montana says.

This understanding includes respecting the nursing home staff's expertise with geriatric patients, and the relationship between the nursing home staff and the patients, she says. Although hospice personnel often care for geriatric patients, nursing home staff members have more experience with geriatric care beyond end-of-life care, so they can offer an expertise the hospice nurse might not have, Montana adds.

Nursing home hospice staff members also must be knowledgeable about the hospice Medicare Conditions of Participation and the regulations governing nursing homes, she says. This knowledge is critical in the development of the plan of care, Montana says.

"Plan-of-care coordination between the nursing home staff and the hospice team is critical," she says. If the nursing home nurse is included in the development of the plan of care, he or she can communicate more effectively to other nursing home staff members, she says.

Hospice staff members also should interact on a face-to-face basis with nursing home staff, suggests Todd. "Talk with the nurse in charge of the patient, talk with the aides, and don't rely on information written in the charts," she says. Personal conversations about the patient's condition will emphasize the importance of working together as a team rather than separate organizations, Todd says.

Communication is important because the care provided by hospice staff does differ, Barton says. "For example, nursing home staff members have narrower parameters for use of medications such as psychotropic drugs as a safeguard for the nursing home resident," she says. "Hospice staff members' parameters are not as strict because they are using the drugs with more expertise."

If the nursing home nurse is involved in the plan of care and the hospice staff regularly talk with the nursing home staff to answer questions and be available to explain different approaches, there is more acceptance of hospice care, Barton says.

Beckwith says, "If hospice and nursing home staff members have a good working relationship that involves sharing information and best practices, all nursing home patients benefit, not just those who are receiving hospice care. A study2 has shown that pain control for all nursing home patients increased when nursing home staff members were able to see how effectively hospice staff members could control pain for their patients."

Although hospice staff can't provide care for patients other than the hospice patients, their explanations of their care prompt the nursing home clinical staff to evaluate better approaches to pain control, she explains.

Although developing a good relationship with nursing homes takes time, it is worth the effort, says David Simpson, president and CEO, Hospice of the Western Reserve. "When we first began working with nursing homes, it was a stigma for a nursing home to allow hospice to provide care to one of the patients," Simpson says. "Now, the nursing home understands the benefits to the patients and the importance of providing care that is needed without having to move to another facility."


1. National Hospice and Palliative Care Organization. NHPCO Facts and Figures: Hospice Care in America. Alexandria, VA; 2009.

2. Miller SC, Mor V, Teno J. Hospice enrollment and pain assessment and management in nursing homes. J Pain Symptom Manage 2003; 26:791-799.

Need More Information?

For more information about hospice services offered in nursing homes, contact:

• Martha Barton, RN, CEO, Pikes Peak Hospice and Palliative Care, 825 E. Pikes Peak Ave., Suite 600, Boulder, CO 80903-3624. Telephone: (719) 633-3400. Fax: (719) 633-3800. E-mail:

• Samira Beckwith, President and CEO, Hope HealthCare Services, 9470 HealthPark Circle, Fort Meyers, FL 33908. Telephone: (800) 835-1673 or (239) 482-4673. E-mail:

• David Simpson, President and CEO, Hospice of the Western Reserve, 300 E. 185th St., Cleveland, OH 44119. Telephone: (216) 383-3773. E-mail:

• Linda Todd, RN, Executive Director, Hospice of Siouxland, 4300 Hamilton Blvd., Sioux City, IA 51104. Telephone: (800) 383-4545 or (712) 233-4144. E-mail: