Special Report: Expanding Hospice to Alternative Sites

Ties with assisted living require unique approach

A little bit of home, a little bit of an institution

(Editor’s note: In this issue, Hospice Management Advisor presents the second article in a two-part special report on how hospices nationwide are beginning to expand their services to treat people residing in long-term-care facilities and assisted living communities. This article features information about making the most of a partnership with an assisted living community.)

Hospice organizations that wish to expand their reach might consider forging ties with assisted living facilities, which are expected to grow in size as the Baby Boom generation ages and retires.

"So much is in synch between hospice care and assisted living facilities, and I think sometimes they’re just overlooked," says Karen Carney, director of community and provider relations at the Hospice of the North Shore in Danvers, MA.

Hospice of the North Shore has a preferred provider relationship with Sunrise Senior Living Inc. of McLean, VA, and also serves patients in about 10 other assisted living communities in the service area, Carney says.

In a little more than a year of working with Sunrise, the hospice’s business with assisted living clients had grown substantially, Carney says.

"We’ve seen steady growth every year in working with Sunrise," she says.

"Sunrise’s efforts to develop preferred provider relationships was a catalyst that caused us to focus on how well we are working with assisted living and how we can do a better job," Carney says.

Statistics provoke stronger interest in hospice

Sunrise, the largest assisted living company in the United States, has always focused on quality-of-life issues, but the company now has extended this philosophy to hospice care after taking a close look at company statistics, says Bobbie Pontzer, MSIM, RN, BSN, national director of hospice services for Sunrise Senior Living.

Two years ago, Sunrise managers discovered that of the company’s more than 200 sites and roughly 20,000 residents, only 2% utilized hospice, Pontzer says.

"The other thing is we’re not a continuum-of-care model where we have nursing care," she says. "Our goal is to keep residents here as long as possible."

If a resident moves in and needs a higher skill level than Sunrise can provide, the facility will work with families to identify all options for keeping the patient in the Sunrise community, including hiring home health aides or providing hospice care, Pontzer says.

Sunrise now has more than 400 sites with almost 45,000 residents, an expansion fueled in part by its acquisition of Marriott Senior Living Services, she says.

Nationwide, the company has a hospice utilization rate of about 8%, while 45 to 50% of Sunrise residents die while residing in the Sunrise community, Pontzer says.

There are pockets of the company where 20% of Sunrise residents receive hospice care, but the lack of faster growth in providing hospice services partly is due to the inconsistent nature of hospice service within an assisted living facility, Pontzer explains.

"We have had a lot of problems with hospices coming into our community," she says. "What we have found was there was a lot of inconsistency in quality of care from hospices and inconsistency in services offered and in collaboration and coordination of that care."

This is why Sunrise has decided to form partnerships with hospices within the communities served by both organizations, Pontzer says.

"Our cofounders are behind what we’re doing in our hospice approach," she says. "So what we did was say, Let’s partner with the best of the best and establish preferred provider relationships with the intent of raising the awareness and quality of services and to educate the hospices about assisted living and senior living.’"

Changing practice assumptions

Through the Hospice of the North Shore’s experience with assisted living centers, hospice staff have learned that some of their practices and assumptions needed to change, Carney says.

"One of the things we stress is the words you use," she says. "Assisted living has its own language, and they would shiver if you call them a facility.’"

Instead, assisted living companies prefer to call their residential sites "communities," Carney says.

"They operate differently than both homes and facilities," she explains. "So one thing we give our staff is a glossary of key words and how you talk their language."

Carney and Pontzer offer these additional tips for how hospices can adapt to working with assisted living organizations:

1. Think in terms of care managers — not aides or caregivers.

Sunrise calls staff who provide aide services "care managers," Carney says.

Who’s responsible for taking temperatures?

"Care managers are the people who attend to personal care needs and follow residents throughout the day," she says. "And if they call us at 11 p.m. and say, This resident who is a hospice patient seems to have a temperature,’ we can’t ask them to take the temperature."

Unlike when a patient is at home or in a nursing home, the hospice nurse must send someone to take the patient’s temperature, Carney says.

"That’s something hospices need to be prepared for," she says.

2. One goal is to keep residents in the assisted living community.

"The goal is to help assisted living residents age in place," Carney explains. "That’s their family members’ goals when they go in there, and that’s the residents’ goals and assisted living staff’s goals, so they live out their days and eventually die there as they would at home."

When patients become ill and are moved to a hospital or skilled nursing facility, the goal remains to return them to the assisted living facility, Pontzer says.

Hospices can assist with this goal by providing additional client support, Carney says.

3. Emphasize how partnering with a hospice can benefit the assisted living community.

Hospices should emphasize the services they have to offer to assisted living residents, including bereavement support for family members, assisted living staff, and other residents, Pontzer says.

"Our team members suffer when they lose a resident because they’re an extended family," she says.

The other benefits hospices offer are the services of hospice volunteers and assistance with medical ethics, advance directives, and funeral home planning.

"We try to be really creative in how we use home health aides, nursing visits, and volunteers," Carney says. "So if we space them out during the day and week, you get a broader spectrum of oversight that might work in concert with what the family can manage."

Another benefit hospices may offer is the provision of durable medical equipment reimbursed through Medicare, she says.

"Sometimes having those costs taken care of can free up money for the family to buy some additional care beyond what the assisted living community can provide," Carney says.

Also, hospices can provide on-call services for staff and residents, and hospice nurses will respond quickly, while it might take a while to reach a family member or doctor, she says.

4. Focus on staff training.

Hospices need to teach staff about the specific needs of assisted living communities in order to achieve the necessary collaboration and coordination, Pontzer says.

"The biggest issue to residents and families is the quality of care," she says. "But we’re also talking about potential license issues."

State regs can affect coordination of care

The assisted living business is responsible for all that happens with residents, so assisted living staff need to have clear communication with hospice staff. If there is a problem that a hospice employee discovers, the assisted living staff will need to know about this immediately, Pontzer says.

"They need to understand our regulations, know the community’s protocols, understand how communication works with the resident’s family, have a grasp on case conferencing," she says.

It’s important to educate hospice employees to understand the differences between the assisted living environment and the home environment, Pontzer adds.

"Who can give the resident medication and how orders should be written depends on state regulations, so hospice staff will need to know how it’s licensed in that state," Pontzer says.

Training is the cornerstone of forging a solid relationship with assisted living businesses, Carney says. "We did a broader, overview training," she says.

Then the hospice managers realized that higher numbers of staff would be required to provide services in an assisted living environment and that more details of this type of work would need to be covered in the training sessions, Carney explains.

For example, hospice nurses need to know the route of communication in an assisted living center. When working with patients at home, the nurse simply will speak with the patient and then the patient’s family. In a skilled nursing facility, the nurse will speak with the resident, family, staff, and physician, most of whom will be found at the nursing home, Carney says.

However, in an assisted living community, the nurse will need to talk with the patient, the family, and certain members of the community’s staff, depending on that site’s preference. For instance, a certain community could want hospice workers to speak to the wellness coordinator or the care manager, Carney says. In assisted living units devoted to Alzheimer’s and other dementia patients, the staff person to contact might be a reminiscence coordinator, she adds.

Other training details that need to be addressed include the nurse’s role at the assisted living site, such as when and how to complete documentation, Pontzer says.

"We have hospices that say, We bring documentation back once a month, and we say, That’s not sufficient,’" Pontzer says. "We need documentation every time they walk into the door."

Perhaps the simplest way to look at it is to understand that the assisted living program is a social model, Pontzer says.

"Most hospices are more of a medical model with a continuum of care, and that’s where we have a disconnect," she says. "It’s like the nurse at the edge of the bed, saying to our resident, You don’t belong here, you belong in a nursing home.’"

Keeping patients at home’

This causes problems and shows a lack of respect for the resident, who feels as though the assisted living community is his or her home, Pontzer says.

"So there needs to be a recognition of this philosophy and this approach in how you communicate," Pontzer says. "If the patient has a higher-skill need, then the hospice nurse can give that freedom of choice back to the resident and family to make a decision about what’s best for them."

And with training, hospice staff will learn how to be sensitive to the assisted living environment when they speak with residents and make recommendations, Pontzer adds.