Long Term Healthcare Conference May 13, 2010

Hospice & Long Term Care

Working Together to Improve End-of-Life Care

Ann Hablitzel RN, BSN, MBA Hospice Care of California

Program Objectives

• Discuss services provided

• Questions to help address the challenges of providing hospice care in a long term care facility

• How to apply practical strategies for building the relationship

Nursing Facility as Site of Death

• By 2020, it has been estimated that 40% of Americans will die in a nursing facility

• Some states have nearly met that level

Home Facility

Philosophy and Guiding Principles of Hospice

• Hospice recognizes dying as a natural part of life and focuses on maintaining the quality of remaining life.

• Hospice affirms life and neither hastens nor prolongs the dying process.

• The nature of dying and of human suffering is understood to be a fundamentally personal experience based on cultural and spiritual traditions.

The Role of Hospice• To support the cultural and spiritual orientation

of the patient and family

• To demystify the dying process

• To assist with resolution of interpersonal and internal conflicts before death

• To help attain a degree of peace in their search for the meaning and purpose of their lives

• To help the patient and family achieve a positive end-of-life experience that is defined by them

Eligibility• Two physicians must

certify that the patient is terminally ill with a life expectancy of six months or less if the disease follows its normal course.

• Patient and/or family are aware of the prognosis and elect palliative care rather than curative measures.

Medical ConditionsAppropriate for Hospice Care

• Cancer

• Heart Disease

• COPD

• Dementia/ALZ

• Stroke

• MS

• Renal Failure

• Hepatitis

• Debility Unspecified

Hospice Care for Seniors(Medicare Eligible)

An HMO senior plan member is still eligible for the Medicare hospice.

For ALL senior health plans, Medicare pays for Hospice - which eliminates the authorization process - which can take too much time when the patient needs care.

Five Domains of Care1. Relieving pain and symptoms2. Avoiding a prolonged death-

relieving suffering3. Maintaining control - their choices

honored4. Relieving others of the burden of

care5. Strengthening relationship

Singer and Colleagues

Services Provided byHospice Care of CaliforniaVisits from

interdisciplinary team

Medications related to the patient’s hospice diagnosis

Durable medical equipment

Dietary counseling

Spiritual counselingVolunteer supportPT, OT, ST, as

necessary to improve comfort/function

Bereavement services for up to one year following the patient’s death

Interdisciplinary Team

• Attending Physician

• Hospice Physician• RN Case Manager• Social Worker• Home Health Aide• Chaplain• Volunteer

Levels of Care

• Routine Level

• Respite Level

• Inpatient Level

• Continuous Care

New COPs – History of Discomfort

“The provision of, and questions related to, hospice care for residents of those facilities has come under scrutiny as a result of a variety of report findings…”

Preamble, Hospice Conditions of Participation

Federal Register – June 5, 2008

New COPs - §418.112

• Incorporated language and concepts from previous sub-regulatory releases

• Did not clarify the areas that have always been puzzling

• Created concern because hospices now have regulations and SNFs/NFs do not

In the Middle of Difficulty Lies Opportunity

Albert Einstein

§418.112(b)Professional ManagementBased on the hospice plan of care and the Medicare regulations, hospice must assume responsibility for professional management of all hospice services provided.

The Reality

Challenging Component

Both parties must continue to provide services at the same level that they would have if the other partner were not involved.

Hospice must only use facility personnel to carry out the Plan Of Care to the extent that they would use family.

§418.112(d)Hospice Plan of Care

• A written care plan must be established and maintained in consultation with facility representatives

• All care must be provided following this plan

Challenging Component

Where shall we start?

One or two care plans?

Care Plan coordination is a common logistical problem.

The burden is really on the Hospice.

Successful Communication

Define the Chain of Communication

Between Hospice and Facility

• In the event a crisis or emergency develops• Change of condition occurs• Changes to the hospice portion of the plan of care• For complaints and other issues

Top Success Factors• Relationships at all levels• Communication• Provide excellent care – deliver what’s

promised• Responsive• Adaptable• Consistent• Shared vision and values• Respect• Benefit to the patient

“You matter to the last moment of your life, and we will do all we can, not only to help you die peacefully, but to live until you die.”

Dame Cicely Saunders

Thank You!!Hospice Care of California