Can home health nurses transition to a blend of curative and hospice care?
Can home health nurses transition to a blend of curative and hospice care?
Combining services may help length of stay
When a long-time chaplain and administrator with Lehigh Valley Hospice in Allentown, PA, left her post in protest of staffing changes, the well-respected hospice found itself in the unenviable position of making internal changes under full view of the community it served.
Ann Huey, MDiv, the former administrator at Lehigh Valley Hospice, departed in December after 15 years as its chaplain when its parent, Lehigh Valley Hospital, decided to blend the nursing services of its hospice and home health programs, something it had been doing on a smaller scale with some of its remote offices. The move, hospice officials said, made sense from an economic perspective. But more important, it would improve quality of care by providing a seamless transition for home care patients who wanted hospice care.
"One of the difficulties is that they [home health nurses] weren’t trained for hospice care," says Huey. Her departure caught the attention of the local newspaper, and Huey expressed her concerns publicly and questioned Lehigh Valley Hospital’s commitment to serving the terminally ill.
Lehigh Valley Hospice and its parent, Lehigh Valley Hospital, stand behind their decision and continue the effort to train home health nurses in hospice care. While officials are unapologetic about the changes, they acknowledge that a better job could have been done to keep staff, physicians, and the community aware of the changes to avoid misunderstandings or the appearance that money was valued over quality of care.
"We had to do a lot of customer recovery," says Bonnie Kosman, MSN, RN, CS, CDE, administrator of Lehigh Valley Hospice.
According to the National Hospice and Pallia-tive Care Organization in Alexandria, VA, nearly six in 10 hospices are owned by hospitals, home health agencies, nursing homes, or some other type of health care corporation.
The number of hospices and home health providers that blend their nursing services is unknown. But industry experts say economic pressures heaped on both the hospice and home health industries point to the possibility of more blended nursing services on an industrywide scale.
For example, hospices have been battling shortened lengths of stay (LOS) with little success. According to the 1998 Data Compendium, published by the Health Care and Financing Administration, in 1994 the average number of days in which a patient remained under hospice care was 60. Two years later that number had fallen to 54. The emphasis has been to influence LOS by lobbying for lawmakers to change reimbursement regulations, such as the required six-months-or-less terminal diagnosis.
Struggling with PPS
Meanwhile, the home health industry has been struggling with Medicare’s interim payment system, which reduced reimbursement by 15%. In October, the new Medicare payment system — the Prospective Payment System — is set to begin, which will place greater emphasis on reducing visits rather than maximizing them. The combined pressures on both segments of post-acute care seemingly beg home health and hospice providers to find joint solutions. Combining services is in the vanguard of innovative solutions.
One such innovative plan in Massachusetts combined hospice nurse services with home health visits. Hospice Care Inc. in Stoneham, MA, has been experimenting with contracting out its nurses’ services to a local home health agency with the hope that their presence would facilitate hospice admissions sooner in the dying process.
With its median LOS at 14 days and its average LOS at 41 days, Hospice Care’s dwindling LOS is typical of the hospice industry. The two most cost-intensive periods of care — program introduction and patients’ final days — were overlapping, often leading to care costs exceeding Medicare’s per diem payment without additional, less cost-intensive days to help offset them.
By using a hospice nurse in a home care setting, the patient is given the opportunity to forge a relationship with a nurse that could potentially carry into the hospice setting.
Industry reality?
Whether or not Huey agrees with her former hospice’s move to combine home health and hospice nursing services, experts agree that similar changes are imminent as both home care and hospice struggle to keep or increase their presence in health care’s continuum of care.
It’s a reality that many don’t seem to have a problem with, provided home health nurses are given the proper training. Blended nursing services allows an organization to consolidate fixed costs, such as rent; consolidate variable costs, including administration; and share resources, says Karen Woods, executive director of the Hospice Association of America in Washington, DC, which operates under the umbrella of the National Association of Home Care, also in Washington, DC.
Woods, who first worked for a freestanding hospice, says there is nothing inherently wrong with home health and hospice nurses sharing duties, but adds that the organization must provide the needed support to help staff make the transition from home health to hospice and vice versa.
"The two clinical specialties can learn from each other," says Woods.
But Huey argues that some home health nurses cannot provide adequate hospice care because caring for the dying requires special attributes, such as a willingness to accept death as a positive outcome and address patients’ and their families’ spiritual and emotional needs. Home care nurses, she says, are trained in the curative aspects of care rather than providing comfort to the dying and their families. "Nurses don’t necessarily make the transition," Huey says. "It confronts them with their own mortality."
Huey’s act of protest is understood by industry experts and to some extent, agreed with, but none condemns the notion of combined nursing services. "There is an element of being called to do hospice work," says David Abrams, senior vice president of the Miami-based Hospice Foundation of America. "We would tend to agree that home care and hospice nursing services should remain separate because in practice it is difficult to make the switch. But theoretically, it’s not impossible. You would have to look at it from an individual standpoint."
Like many hospices, Lehigh Valley was struggling financially. The hospice and home care programs are housed in four branch offices. Out of necessity, two were already providing blended nursing services, says Kosman.
When hospital officials compared the performance of the branch offices, they found that lengths of stay were dramatically different. In the offices where hospice nurses and home care nurses maintained separate patient populations, average hospice LOS was about 14 days, similar to the rest of the hospice industry.
But the numbers produced by the two branch offices where nurses provided both home care and hospice visits told a different LOS story. Rather than LOS hovering at about two weeks, patients were averaging four to eight weeks in hospice.
"We heard from the offices that operated separate hospice and home health nursing services [that among] home health patients who were eligible for the hospice benefit, 99% of the time the family didn’t want to give up the relationship with their home health nurse," says Kosman. "In some cases, we had home health nurses providing care until the patient died."
Huey acknowledges that LOS is a problem and that hospices must find a solution so that they can remain viable. "To a degree, I do agree with [having to reach patients sooner]," she says. "For example, I think every hospice should provide pre-hospice palliative care. It honors the mission of hospice."
Forced to choose?
Combining hospice and home health nursing services can lead to disagreements over which visit is more important, Huey says. She recalls a situation where an on-call nurse was forced to choose between visiting the home of a dying patient and a patient who needed antibiotics administered. The nurse chose to administer the antibiotics, and the hospice patient passed away without a hospice worker present.
"It’s terribly unfair to make the nurse have to choose," Huey says. "The home health patient had an immediate medical need, but the family of the [dying] patient may have been distressed and needed the reassurance of the nurse."
Incidents such as the one described by Huey are more a function of communication problems between nurses and their supervisors, Kosman says. If a conflict arises and the nurse advises her supervisor, arrangements can be made to accommodate both patients, Kosman says.
Aside from Huey, 10 nurses quit. Four have since asked to come back, Kosman says. "The 10 new nurses that we hired are adapting very well," Kosman says. "That’s probably because they bought into the system right away without having anything to compare it to."
Giving due credit
Like Woods, Kosman firmly believes that home health nurses can provide high-quality hospice care given the proper training. She doesn’t agree that good hospice nurses have a higher calling.
"What Ann said about home health nurses not being able to provide quality hospice care left those who have done it extremely insulted," Kosman says. "She didn’t give credit to those nurses who have done it day in and day out. I think some hospice nurses have become very comfortable in saying they have been called to their work. But I think that reflects their own needs. It’s been my experience that nurses who do say that are the last to use the resources available to them and try to do everything on their own. I have seen home care nurses acknowledging that they can’t do it all and use other members of the interdisciplinary team."
Without insider knowledge of what went on at Lehigh Valley, Woods’ take on the issue is that of resistance to change. "Change can be painful, especially if you’ve been in one place for a long time and are used to seeing things a certain way."
Softening the blow
That’s why Kosman says better communication in the beginning would have gone a long way to softening the blow of change. Looking back, she offers a few nuggets of advice for organizations going through similar changes:
• Communicate changes that will affect all your customers — the community, clinical staff, and referring physicians.
At first, some physicians seemed reluctant to refer their patients to hospice because of the controversy, says Kosman. Yet, once physicians understood what the organization was trying to accomplish, many were eager to take part in helping home care nurses learn the important aspects of hospice care.
• Go slower with staff.
Allow for effective communication of the education process before sending them out on their own. Part of that education should be communicating how the change will affect them and what will be expected of each staff member. Lehigh Valley used nurses who were already providing both hospice and home care service as trainers and mentors. Home health nurses performed joint visits with a hospice nurse to observe how things are done differently and to help them adjust to palliative care.
• Pay for inservice training.
"We knew we had to make a significant investment," Kosman says. Nurses were required to participate in one-hour to 1.5-hour training sessions twice a month, where they learned the theory behind hospice care, the differences between palliative and curative care, and learned about documentation differences.
For those who are opposed to blending nursing services, Kosman says the demands on both industries require both segments to look at care from a macro perspective. "We’re looking at the big picture," Kosman says. "Lehigh Valley Hospice is part of a larger organization that is committed to addressing care across the continuum."
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