Emphasize what you can do for them
When a hospice manager visits with a nursing home director to discuss hospice referrals, the focus should be on more than just what the hospice can do for patients; emphasis also should be placed on what the hospice can do for the skilled nursing facility (SNF) and its staff, experts advise. That’s just one of the tips hospices could follow to increase business through SNF referrals and collaborative relationships. Here are some additional suggestions for developing and maintaining collaborative relationships with SNFs:
1. Show how the hospice can support the SNF’s mission.
"Figure out where you fit in with them," suggests Karen Carney, director of community and provider relations at Hospice of the North Shore in Danvers, MA. "It’s not just going to them to say, Do you have somebody ready for hospice?’" Carney says. "It’s knowing where you add value."
The biggest marketing point is that a hospice has expertise in palliative care and symptom management, and hospices have resources to handle these issues that a nursing home probably lacks, Carney says. "Bringing in hospice services helps them expand what they are able to offer," she says.
"When I talk about the benefits of hospice, I’m talking about the benefits to patient care, such as another set of eyes and ears and an interdisciplinary team that relieves the burden on the nursing home’s staff," says Gwendolyn Burk, MSS, MEd, LCSW, manager of the assisted living and skilled nursing facilities team at Hospice of North Central Florida in Gainesville. "Hospice can help increase staff satisfaction in facilities because we provide education and support to them, and that decreases burnout and turnover," Burk says. "Hospice is very proactive in pain management and crisis care, and this helps to make sure every resident has a smoother stay."
Hospice managers also should talk about the benefits to residents, says Marion Keenan, MA, MBA, president of Coastal Hospice in Salisbury, MD. "That’s the bottom line and that’s our reason for being," Keenan says. "The other thing I do try to talk about is the beneficial aspects of our presence on their professional staff as colleagues."
For example, hospice’s presence brings the SNF an additional nurse with whom to collaborate, another social worker involved with a patient, pastoral care, and additional aide services, all of which help the nursing facility, Keenan says. "I think nursing facility staff feel less guilty when they see a patient near death and hospice is there with them, so they don’t have to feel like they’re ignoring that patient," she adds.
Keenan also explains to SNF directors that patients and their families typically have a more favorable impression of a nursing facility when hospice is there, because they don’t separate hospice services from the SNF’s services. "They think about the overall care that Mom or Dad got in this facility, and so there’s more satisfaction overall," Keenan says.
2. Understand financial drawbacks.
SNFs benefit financially from being able to bill Medicaid for a resident’s room and board and then billing Medicare for any rehabilitation the patient might need, Burk explains. However, when a patient is referred to hospice, the Medicare portion of reimbursement ends for the nursing home, and it’s the hospice that bills Medicare for palliative care services. So some SNF directors may weigh the financial drawbacks of bringing in hospice.
Another issue that may concern SNF directors involves the convoluted way Medicare and Medicaid pay for SNF residents when hospice is involved. The typical arrangement is for Medicaid to pay the SNF directly for a client’s room and board, says Diane Hoffmann, JD, MS, professor of law, associate dean for academic programs, and director of the law and health care program at the University of Maryland School of Law in Baltimore.
Hospice involvement may delay SNF payment
Once the hospice is involved, both Medicare and Medicaid pay the hospice directly for the patient, and it’s up to the hospice to pay the nursing home the Medicaid portion, Hoffmann says. "Nursing homes in many states get paid electronically from the state Medicaid, and hospices may not be paid that way, so the timing of the payment to the nursing home is much slower, and nursing homes may see that as a problem," she says.
3. Maintain strong communication lines between the hospice and the SNF.
Hospice of North Central Florida staff first meet with SNF staff to establish parameters of care and to learn the exact needs of a patient, Burk says. "In terms of collaborative practice, we’d meet quarterly with facility staff to see if everything is going as well as it needs to be," Burk says. "We’re involved in patient conferences and will document any education or anything that has to do with the [SNF] staff."
For instance, the hospice will offer SNF staff inservices on pain management and other topics at least quarterly, Burk says. "We offer an interesting class on the signs and symptoms of approaching death," Burk says. "The social worker and nurse discuss this and give facility staff time to say what they’ve seen and how it affected them."
The hospice’s chaplain has conducted patient memorial services for both surviving SNF residents and also for staff, Burk notes. "There are lots of layers of support, and one of the things that’s important is for staff to feel they are not out there doing it alone," Burk says.
4. Train staff to work in an SNF environment.
If possible, a hospice should place nurses and staff with backgrounds in long-term care work in SNFs, Carney suggests. "The secret to what has helped us grow long-term care volume is we specifically recruited nurses with a long-term care background because they know what it’s like to be on the other side of the desk," Carney says. "SNF nurses don’t want hospice nurses to come in and give the impression that they know how to do it better."
Also, hospice nurses with SNF backgrounds will speak some common language more easily. For example, SNF nurses use acronyms such as MDS, which stands for minimum data set, and MMQ, which stands for managed minute questionnaire, and a hospice nurse with a background in long term care will know immediately that the MMQ is a tool that determines the Medicaid reimbursement rate paid to the nursing home for a patient, Carney explains.
Another strategy is to teach hospice staff that they are guests in the facility and will be working there as consultants who are trying to help the facility, she says. "One of the other things we do is assign all of the LTC team to specific facilities, and that way they really develop a relationship with the staff at the facility and are comfortable with each other," Carney says. "There is a consistent person coming in and a consistent way of doing things."
At Hospice of North Central Florida, most of the staff are seasoned professionals, and some come from the SNF environment, Burk says. "They have a strong sense of advocacy for older people," Burk says. "As we interview people, we look for people with really good interpersonal skills and a sense of diplomacy."
Staff are trained in a week-long orientation, followed by a one-month orientation on a team, Burk says. Part of the training for hospice staff who will be working in nursing homes is to emphasize the importance of having an attitude of mutual respect, Keenan says. "And the people who are most important in making that happen are the leaders," Keenan adds. "So it’s important for me and the nursing facility administrator to keep encouraging staff to be open to the suggestions and perceptions of the other group."