How some hospices combat late referrals
How some hospices combat late referrals
Hospices who recognize that the answer to dropping lengths of stay may lie in better data have begun gathering targeted in-depth information from patients, families, physicians, and other referral sources.
To that end, some hospices are using mail surveys, focus groups, and a closer analysis of utilization data.
"We are now asking [each new patient] what’s been going on in their lives over the past month," such as medical treatments or home care, says Connie Holden, RN, MSN, director of Hospice of Boulder County (CO). "We also sent out our annual physician survey with seven new questions aimed at identifying barriers to hospice admissions." (See copy of the physician survey, inserted in this issue.) The hospice also plans to convene a focus group of physicians to ask about the referral process and to meet with referral sources, especially new physicians in the community in key specialties.
Physicians need education on services
Preliminary results from the physician survey have been revealing, Holden says. "We’ve had a special services [pre-hospice] program for a couple of years now. Does anyone know about it? No. Physicians also don’t know that we’ve loosened our policies regarding aggressive treatments. The gap between what we think we’ve taught them and what they actually know is huge, and it has given us some hope that there are things we can do better to achieve positive results. If we had found that they knew exactly what we’re about and still weren’t referring appropriately, that would be more disheartening."
However, reaching physicians with the information is no easy trick. Would doctors come to a hospice 101 course, even when evidence shows they need it? Holden wonders. The hospice plans to send a newsletter to physicians in the community. "Whether it changes referral patterns or not that will be the proof."
At Hospice of Petaluma (CA), CQI coordinator Marilee Blonski, RN, MSN, and liaison nurse Teresa Lyons, RN, CRNH, sought solid data to explain declining lengths of stay. They started by examining every short stay (30 days or less) referral in a six-month period, along with a control group of longer-stay patients. The hospice is now analyzing data on diagnosis, referral source, physician, setting (home vs. nursing home), staff time required, and average cost per day, as well as the results from a focus group of physicians, patients, and families.
"One clear message we got is that hospice means death because it represents dying, so people aren’t willing to look at our scope of services. They struggle along as long as possible," Lyons observes.
"We also added a question to our family surveys, asking whether an earlier referral would have helped. For the most part they said, No.’ The population we serve doesn’t seem to see that as a problem," adds Blonski.
Hospice liaisons can bridge the gap
Since physicians have a difficult time introducing the hospice concept, Hospice of Petaluma has offered to send a staff member to the physician’s office to meet with the patient, family, and doctor. "My experience in doing this is that you don’t have to say a lot just listen to them," Lyons says. "Another thing that happens is that the patients see hospice and the physician in partnership together. The physicians aren’t abandoning them but are working with hospice."
Although these meetings are usually well-received by families, physicians rarely take advantage of the service. "Another clear message from our focus group is that a lot needs to be done with the culture at large, working with the stigma of death," Blonski adds. "One thing we’re looking at is offering forums in the community around issues such as living wills so we can broaden the horizons of hospice beyond its narrow focus, allowing people to talk about these issues well before they need hospice."
After analyzing lengths of stay data, Jan Cetti, president and CEO of San Diego Hospice says, "What we uncovered is a tremendous lack of understanding about the hospice benefit by other providers and a tremendous lack of awareness even of the differences between home health and hospice." As a solution, the hospice is exploring partnerships with home care providers to create bridge programs to ease patients’ transition to hospice.
One possible result of gathering better data might be a realization that shorter stays are inevitable. Hospices may need to explore reconfiguring their services, perhaps hiring and training staff to manage the crisis-oriented care of very short stay patients. For example, the admission team might also provide more concrete nursing services to patients and families on the first meeting. Or this may require scheduling the first chaplain visit earlier or redefining the chaplain’s role.
"We have to think differently about how our services are offered and delivered," says John Carney, president of Hospice Inc. in Wichita, KS.
"We’ve talked about being a smaller agency," given shrinking lengths of stay and a decrease in referrals for three years in a row, adds JoAnn Siemsen, MPA, executive director of Hospice Caring Project of Santa Cruz County in Aptos, CA. "We’re looking at cutting costs doing things in different ways trying to make changes in our vendor relationships. But our staff are dissatisfied with what’s happening."
Hospice SWATteam’
"I heard about a Canadian program which had a kind of "SWAT team" that was called in for patients in the last few days or even hours," says Peter Moberg-Sarver, president and CEO of Hospice of Central New York in Syracuse.
"Hospices surely are doing that already," says Gretchen Brown, MSW, president and CEO of Hospice of the Bluegrass in Lexington, KY. "You have to give up your ideas about how often people get visited." But this kind of care would be more expensive than the hospice benefit Medicare now covers, Brown says.
"I think we need to look at the hospice payment system so that it takes into account our current realities," she adds. "We need a different payment mechanism than the one invented in 1983. Something is badly out of whack."
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