Bridge connects hospice with home care patients

Adding palliative, emotional services to home

Any home health nurse knows that there are many seriously ill patients who could benefit from some of the symptom management and emotional support traditionally found in hospice programs.

For patients at VNA of Crossroads in Mt. Vernon, IL, there is no longer a choice to be made between hospice and home care. Debra Karnes, RN, director of professional services for the agency and Barb Carter, RN, CRNH, patient care coordinator at VNA of Illinois Hospice, also in Mt. Vernon, developed a program that works as a bridge between the two. "There are a lot of patients who need home health care, but can benefit from the hospice approach," Carter says.

"This gives them that additional choice and acts as a bridge for those who are on their way into hospice but still want aggressive treatment," Karnes adds.

The National Hospice Organization in Arlington, VA, has been talking about bridge programs for about a year, Carter says. Fortunately for Crossroads patients, VNA of Illinois Hospice was approached by Barnes Jewish Hospital in St. Louis, which has a large and successful bridge program.

For the last six months, cancer patients, cystic fibrosis patients, and patients with end stage congestive heart failure and lung disease have taken advantage of the program. No patient satisfaction surveys have been done on this population. By its nature, many of them die in care, however, all patients who move on either to hospice or who are discharged are asked their opinions about the program, and thus far, Karnes says reactions have been positive.

What has surprised Karnes is the number of patients who have died. "We would have thought more would have moved on to hospice, but we had more die," she says. "But we think they died more comfortably."

The biggest requirement for successful implementation of a bridge program is having nurses who are cross-trained in home care and hospice. Crossroads has two hospice nurses, and its other nurses have had at least basic hospice training. Patient intake is done by Karnes or her assistant. If the patient seems an appropriate candidate for the bridge program, the social worker or physician on the case is approached. They, in turn, approach the patient with the program. If the patient agrees, one of the two hospice nurses is sent in to admit the patient and coordinate all care.

"Patients who are unsure about hospice care can then get the emotional support they need, but they can still feel the decision they made is OK," Karnes says. "Our nurses do have to be a little schizophrenic. We say that they have to both be there to prepare a patient for death but also keep them focused on treatment."

Hospice nursing has an added benefit that patients who want aggressive cancer treatments haven't had access to before from traditional home care - the symptom management which hospice nurses are specially trained in. Carter says there is no reason this program couldn't be expanded in the future to give other cancer patients facing chemotherapy and radiation treatment access to the expertise of the hospice nurses. "It's covered the same way home care is. We know others could benefit from it."

The biggest problem is communication, Carter says. "You have to have people who are willing to move both programs, who can bounce easily from hospice to home care. It isn't the visits which are difficult. It's the paperwork. We have to go by home health care rules and paperwork, which means hospice nurses have to learn that aspect and understand it," she says, adding that Crossroads handled that issue through a one day inservice training.

Cost is another issue, says Karnes. Any program which has caps on the amount of care you can give could run into problems with a bridge program. "Watch your costs and track them," she suggests.

Yet, costs and administrative issues aside, Karnes says hospice nursing is a valuable treatment option for her patients. "We are giving them a choice about whether or not to have treatment. Just because they choose to treat their illness doesn't mean they should be denied emotional care or symptom management."