Michigan hospice shows how to bridge gaps between hospice, nursing homes

Conflicting policies cause opportunities to be lost

There are strong indications that hospices are making progress in improving the plight of end-of-life patients in the nation’s nursing homes. Even so, experts say, substantial regulatory and cultural barriers remain to make it a daunting task.

In 1997, the Institute of Medicine issued a report citing problems with end-of-life care. The report mentioned nursing homes as sites where care could be improved through better provider education. Since then, the hospice industry has been on a crusade to improve hospice access for patients in nursing homes.

The long-term care expert for the Alexandria, VA-based National Hospice and Palliative Care Organization (NHPCO) says hospices have increased nursing home patients’ access to hospice. "I can’t say for sure whether hospices are doing a better job [of treating nursing home patients], but if you look at the Medicare numbers, there has been an increase in payments made for room and board," says Cherry Meier, MSN, long term care manager for the NHPCO.

While there is no research to indicate whether progress has been made, there has been an increased understanding of the need and value of hospice in nursing homes, says Tom Burke, a spokesman for the American Health Care Association in Washington, DC. The association represents more than 12,000 assisted living facilities.

If what Meier says is true, then hospices have been able to overcome the barriers that stood between the two disciplines in the past. Experts from both disciplines have said each side needed healthy doses of education about the other’s goals and practices in order to increase understanding and foster cooperative work arrangements.

Hospice of Michigan in Detroit is one program that has successfully crossed regulatory and cultural boundaries. Of the 900 patients the hospice cares for daily, about 300 of them are in nursing homes, says Michael McHale, MHA, NHA, corporate director of marketing.

"It’s about relationship building," says McHale, a former nursing home administrator. "We tell them we want to be part of their team."

Hospice of Michigan is an example of how hospices can transcend previously held beliefs. Nursing home staff often believe that hospice care in their nursing homes is a duplication of effort, but they are often unaware of hospice’s psychological, social, religious, and cultural programs that can benefit their patients.

Despite regulatory barriers, some nursing homes and hospices manage to work out arrangements that avoid regulatory missteps and benefit both organizations. An estimated 13,369 Medicare hospice beneficiaries reside in Medicare/Medicaid-certified facilities on any given day. For the most part, hospice beneficiaries are being served in nursing homes that do not have specialized hospice units, because few nursing homes have such units. Nursing homes with higher percentages of residents receiving hospice care are more likely to be for-profit, belong to a chain, and not provide full-time physician coverage.

So how can hospices and nursing homes foster continued cooperation?

The answer, says McHale, is to bridge the knowledge gap, build trust, and show nursing homes the benefits hospice care will bring to the facility and its patients.

McHale says hospice can provide the following specific benefits to nursing homes:

  • help for the nursing home’s bottom line;
  • relief for staffing burdens;
  • a boost to admissions;
  • credit for quality of care from independence to the end of life.

The challenge, says Burke, is for the two disciplines to coordinate care while reconciling differences in policies and procedures. For example, nursing homes operate under strict assessment schedules that are tied to reimbursement, while hospices do not. Even though a nursing home resident is under the care of hospice, the nursing home is still responsible for routinely obtaining and submitting a lengthy patient assessment called the Minimum Data Set (MDS). Because hospice staff are not experienced in using the MDS, proper filing of the form is made difficult.

Hospice perspective

Educating nursing homes about hospice care is the key to developing steady referrals to hospice. Nursing home staff are not trained in palliative care and don’t understand hospice’s intentions to treat pain proactively. No one can blame the lack of knowledge about hospice care on anyone other than hospices themselves. They are missing opportunities to educate nursing home staff.

In addition to regular training, hospice workers need to have an ongoing training component for nursing homes. Ways to accomplish this include:

  • When visiting a patient, bring written literature about your hospice and its mission to the nursing home to help you educate new nursing home employees who have not yet sat through hospice inservice training.
  • Invite nursing home staff to your hospice’s hospital inservice training.
  • Make your palliative care services available to nursing homes. Even though a hospice cannot receive payment unless the patient has a terminal illness diagnosis, this gesture provides excellent goodwill, which will lead to future referrals.

Following are the top 10 areas in which nursing homes and hospices can become entangled in conflicting policies and regulations:

1. Coordination of billing. The two organizations, says Meier, need to work out who is going to bill for which services. This includes understanding the responsibilities of clinical management of the patient and distinguishing routine care provided by nursing home staff.

2. Patient self-determination and advance directives. Both organizations are responsible for verifying that patients’ rights to informed consent are being respected. To ensure patients’ wishes are being carried out, nursing homes are required to inform patients of their right to formulate an advance directive that establishes special power of attorney, a living will, and a medical treatment plan. For the hospice’s part, it should make sure to obtain an informed consent form, signed by each patient, specifying the services that can be provided by the hospice.

3. Resident assessment. As mentioned earlier, hospices must cooperate with nursing home staff to ensure timely completion of the MDS, either by agreeing to complete the form based on working knowledge of the patient or by providing the needed information to nursing home staff responsible for completing the MDS.

4. Comprehensive care plans. While both hospices and nursing homes have care plans, they come with different requirements. For example, nursing homes are required to review and update their care plans every 30 days for skilled-nursing patients and quarterly for long-term-care patients. Hospices do not have the same requirements. The result can be two care plans for the same patient evolving in two very different ways. Both organizations must strive to coordinate their care plans so they account for each other’s goals and are updated at the same time. Care plans should be coordinated, with the hospice care plan building upon the existing nursing home care plan, says Burke.

5. Professional communication. To facilitate the coordination of care plans, standard mechanisms should be in place for each provider to notify the other of changes in the care plan or changes in the patient’s condition. Each organization should designate a staff member as the person to call when changes are made and to coordinate how the changes will be handled. For example, a hospice might designate the on-call nurse as the liaison so the nursing home is assured of reaching a nurse who is able to make sure changes are noted and care is provided in a timely manner.

6. Interdisciplinary team. Both nursing homes and hospices use a variety of disciplines to treat their patients. Each organization depends on the interaction of these disciplines to help determine the best course of care. When a hospice comes into a nursing home, the need to recount observations and communicate changes in care does not diminish. There is a need for both interdisciplinary teams to work together. Each organization should include a representative from the other’s team to act as a liaison between the two groups.

7. Physician services and visits. Hospices need to teach nursing homes that physician-directed interdisciplinary care is an essential component of hospice. The nursing home physician must clarify his or her role with hospice, including whether the nursing home physician or the hospice medical director will certify the care plan and services to be given.

Different medication rules can cause problems

8. Medications. This area has the greatest potential for conflict. Nursing homes must follow specific regulations for certain drugs, such as psychotropics and anti-psychotics. Before nursing homes can use these drugs, there must be a specific diagnosis, such as depression or mental illness. Hospices, on the other hand, use some of these drugs routinely as part of the pain management arsenal. A conflict can arise when a hospice has placed a resident on one of these drugs to manage pain, but a nursing home nurse refuses to administer the drug because the patient doesn’t have the required diagnosis. If the nursing home nurse is properly educated about the hospice’s pain management plan and is told why the drug in question is being used, the patient will not be forced to suffer needlessly while the two sides straighten out their differences.

9. Clinical records. When a hospice treats a nursing home resident, it must establish a patient record. But that record also represents care delivered while the patient is a resident of the nursing home. Nursing homes and hospices must agree on how they will share their records, including which organization keeps the original copy.

10. Nursing home staff training. Hospices need to establish a collaborative training program with their nursing home partners. Hospices often treat facility staff training as a work in progress. In order for training to take root, hospices must make sure nursing home administration is taking part. With high-level management participation, there is a greater likelihood that the concepts taught will remain with the organization despite the high turnover rate of nurses and aides.

Getting nursing homes to make regular referrals will be an arduous process for hospices. There are deep-rooted territorial issues to overcome, on top of misperceptions of hospice care. But that doesn’t change the fact that there are nursing home residents who are dying and need the comfort of hospice care.