Hospice/Nursing Home Interface
Guidelines for Care Coordination for Hospice Patients
Who Reside in Nursing Homes
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SECTION IV -
CLINICAL PROTOCOL DEVELOPMENT
Effective coordination of care that assures patient needs and
regulatory requirements are met necessitates careful planning by both the
nursing home and the hospice. The development of policies and protocols
that define care coordination issues is essential to ensure consistent
quality.
1. PRIORITY AREAS
Priority areas have been identified for consideration in the
development of clinical protocols.
Admission Process
Physician Orders ;
Supplies and Medications ;
Medical Record Management ;
Hospice
Core Services ;
Death Event ;
Quality Assurance/Performance
Improvement ;
Emergency Care
a) Admission Process
Protocols should be developed that clarify the process of admitting a
current nursing home resident to the hospice program, a current hospice
patient to the nursing home, and lastly for the simultaneous admission of
a patient who is new to both the hospice and the nursing home.
Referral of resident made to Hospice made by nursing home or others.
Consult/information provided by Hospice.
Patient/resident meets hospice admission criteria and chooses to pursue
admission to Hospice Care.
Hospice conducts assessments, secures orders from the physician and
manages orders from this point.
Nursing Home assesses if significant change of condition has occurred
that requires a new comprehensive assessment using the resident assessment
instrument (RAI). Refer to Chapter 2, page 2-8 of the "Long Term
Care (LTC)-Resident Assessment Instrument User’s Manual (exit DHFS)" related to
significant change in status assessments.
Hospice makes referral to nursing home: the hospice may initiate
contact with the nursing home and facilitates communication between the
patient/ family and the nursing home representative.
Hospice and the nursing home coordinate securing required admission
paperwork (i.e., history and physical, TB screening, physician orders,
etc.).
Reference BQA memorandum 96-025, dated May
2,1996, Waiver of HFS 132 Wisconsin Administrative Code for NH residents
electing hospice services.
Transfer of patient to nursing home: the provision of hospice services
continues in the nursing home on day of transfer.
RAI process and subsequent revision of care plan developed by nursing
home/hospice.
Referrals made to hospice and nursing home.
Hospice and nursing home coordinate the admission process and required
paperwork.
Transfer of patient to nursing home-hospice involvement begins on day
of transfer.
Initiation of the RAI process, assessments and care planning process by
the nursing home and the hospice.
b) Physician Orders
Hospice is responsible for securing medical orders and assuring they
are consistent with the hospice philosophy.
Individualized standing orders for symptom management are obtained by
the hospice from the attending physician and provided to the nursing home.
. These orders may be initiated by the hospice according to patient need
and as identified in the comprehensive plan of care.
Nursing home patient specific standing orders may be utilized (based on
contract), if they are consistent with the hospice philosophy and
specified on the plan of care.
All verbal, phone and written orders must be authorized by hospice
before initiated.
Laboratory tests or other diagnostic procedures related to terminal
illness must be pre-approved by hospice and specified on the plan of care.
The nursing home coordinates the scheduling of routine physician visits
(and/or nurse practitioner visits). . Under state and federal law
applicable to nursing homes, a nurse practitioner may be utilized after 30
days of the first 90 days, and after 60 days thereafter. . "Certified
Registered Nurse Hospice" (CRNH) does not qualify as an advanced
practice nurse.
Hospice nurse may communicate the physician order(s) to the nursing
home nurse.
c) Supplies and Medication/Contracted
Services:
Supplies and medications related to the management of the terminal
illness are the responsibility of the hospice. The nursing home and
hospice should coordinate obtaining and monitoring the following supplies
and services according to the terms of their contact:
Prescription medications related to the terminal illness (medications
supplied by hospice must meet nursing home pharmacy labeling and
distribution requirements).
Durable medical equipment (DME), i.e. ,
wheelchair, walker, bath bench, commode, oxygen, etc. that are related to
the terminal illness.
Disposable medical supplies related to the terminal illness, as
specified in the plan of care.
Provision of contracted services such as physical therapy, occupational
therapy, speech therapy, dietary, etc., related to the terminal illness
should be specified on the plan of care and clarified in the contract.
d) Medical Record Management
Copies of physician orders and coordinated plan of care should be on
medical records of both organizations. The location of the original
orders should be based on the contract.
Copies of hospice informed consent and current physician certification
must be on the nursing home chart.
Original RAI/MDS information stays with nursing home record and may be
copied to hospice based on the contract.
The patient's record in the nursing home will confidentially identify
the person as a hospice patient.
If specified in the contract, both the hospice and nursing home retain
copies of all or parts of the other's record following death or discharge
of a hospice patient.
The records of a patient residing in the nursing home must include all
clinical information that is relevant to the care of the patient (orders,
data assessment, etc.), whether obtained by the hospice or the nursing
home.
The clinical information must be included in the records maintained by
each provider.
If admitted to the hospital, copies of transfer bed hold agreement if
indicated.
e) Hospice Core Services
Core services as defined in the Code of Federal Regulation (CFR)
include nursing services, medical social services, physician services
(medical director), and counseling services. These services are to be
provided routinely directly by the hospice employees and cannot be
delegated to the nursing home. All covered hospice services must be
available as necessary to meet the needs of the patient.
1) Nursing services
Nursing care is a core service of hospice for assessment, intervention,
and evaluation.
The hospice may involve nursing personnel from the nursing home to
assist with the administration of prescribed interventions if specified in
the plan of care. This involvement would be to the extent that the hospice
would routinely utilize the patient's family/caregiver in implementing the
plan of care.
2) Medical Social Services
Social services constitute a core service of hospice for assessment,
intervention, and evaluation related to the terminal illness.
Other social service interventions may be provided collaboratively by
hospice and nursing home social workers based on the plan of care.
3) Counseling Services (Bereavement/Dietary/Spiritual/other)
Counseling is a core service of hospice for assessment, intervention,
and evaluation related to the terminal illness (type of counseling is
defined by individual hospice).
Bereavement services are a required service for licensure per Wisconsin
Administrative Code, HFS 131.42 (3)
(d) (exit DHFS).
Additional counseling interventions may be provided collaboratively by
the hospice and nursing home staff based on the plan of care.
4) Physician Services
Physician Services are a core service of hospice for assessment and
evaluation. The Hospice Medical Director provides this service.
Attending physician services may be provided by the Hospice or Nursing
Home Medical Director, the patient’s attending physician, or their
designees.
Consulting physicians may be involved. . Coverage for attending
physicians is provided by consulting physicians. The hospice is
responsible for arranging consulting physician services.
5) Other (non-core) services
CNA/HHA should be provided collaboratively by the hospice and nursing
home based on patient need and as specified in the plan of care (clarify
in contract).
Therapy services (physical therapy, occupational therapy, and
speech-language pathology) should be made available based on patient need
and as specified in the plan of care.
Volunteer services are to be coordinated by the hospice but may be
provided collaboratively by the hospice and nursing home as specified in
the plan of care (clarify volunteer role in contract, especially related
to hands-on care).
f) Death Event
Death is an anticipated event for the hospice patient. Protocols should
be established to define mutual responsibilities at the time of death:
The hospice must be notified, make a visit and coordinate the death
pronouncement.
Review state, county, and facility guidelines regarding coroner/medical
examiner involvement, and follow the protocol specified in contract for
notification.
Nursing home and hospice coordinate notification of physician for
release of body when heart rate and respiration have ceased.
Medication disposal.
Specify hospice and nursing home role in supporting the resident’s
family/caregivers and nursing home staff.
g) Quality Assurance/Performance
Improvement
The nursing home and hospice are required to implement quality
assurance/performance improvement activities per respective regulations.
A collaborative approach to problem solving and outcome monitoring is
encouraged for inter-related issues.
h) Emergency Care
Emergency care is defined as unexpected and may or may not be
related or unrelated to the terminal illness.
Care should be consistent with the patient's stated wishes in the
advance directive, and with the physician's orders including
cardiopulmonary resuscitation.
Nursing home staff provides immediate care in conjunction with facility
policy and/or based on plan of care.
Nursing home staff must notify hospice immediately of patient change of
condition for further assessment and revision of plan of care as specified
in the contract.
2. PLAN OF CARE:
The nursing home and hospice must coordinate and establish a plan of care for both providers which reflects the hospice
philosophy, and is based on the individual's needs within this and unique
living situation. For further information related to
care planning for the resident who has a terminal illness, please refer to
the care planning 2000 guidelines (PDF,
293 KB) distributed via
BQA memorandum 00-022.
Each nursing home and hospice should develop policies and protocols to
accomplish the MDS/RAP care plan process.
a) Use of the Resident Assessment Instrument, Including the MDS, in the
Care Plan Process
General Framework for Decision-Making
Nursing homes are required to use the Resident Assessment
Instrument (RAI), that includes the a minimum data set (MDS), for all
nursing home residents, including for residents who choose hospice. The MDS is completed at the time of
admission and periodically through out a resident’s stay. A new comprehensive
assessment is required when there is a significant change in status that
meets the definition in the RAI. The RAI definition addresses end stage
disease and the need for significant change of condition (SCOC)
assessment. (Refer to RAI manual for specifics).
Recommendation #1:
The initial RAI is very important and includes the MDS, as well as
the periodic reviews. Sharing
of information and collaborating in this process is strongly
encouraged. It is essential that the hospice core team and the
nursing home staff both derive patient care decisions from the same
core set of patient data.
Many of the patient-change criteria that can trigger the need for
generation of a new MDS for terminally ill or dying patients are, in fact,
changes that are a natural, expected outcome of the progression of a
terminal illness and/or the dying process. . In these situations, the
patient care benefits of generating a new MDS are minimal at best, and are
far outweighed by the intrusion to the patient that the process of
developing a new MDS entails.
Recommendation #2:
Refer to the Center for Medicare and Medicaid Services (formerly Health
Care Financing Administration’s) RAI
Manual
(exit DHFS), page 2-11 for information
related to End-Stage Disease Status.
When a patient changes from a rehabilitation/curative course of
care to palliative care, the initial change-of-condition
minimum data set (MDS) may be the final change of condition MDS. In
this situation, the changes in condition are anticipated and
documented as part of the progression of the terminal illness and/or
dying process. Periodic reviews (quarterly and annually) reviews are
still required.
Illustrated as a process, this statement would look as follows:
TRIGGER - Change in Patient Condition (after hospice election)
NOTIFY AND REVIEW - Nursing home reports change to hospice and initiates a
RAP review jointly with hospice staff
DECISION - The hospice and nursing home staffs make a two-fold
determination: (a) is the change in condition related to the
progression of the terminal illness, and (b) was the change already
anticipated and documented on the MDS?
ACTION:
-
If "YES" to both questions: No new
comprehensive assessment; hospice and nursing home staff address
changes through the plan of care.
-
If "NO" to one or both questions: New comprehensive
assessment by the nursing home staff and/or hospice and shared by
the two agencies.
Revisions could be made in the nursing home’s approach to the RAI/MDS
process that would protect quality of care for patients by forcing a
review of the patient’s condition against the changes expected and
documented as part of the progression of the terminal illness and/or dying
process. Additional triggering a SCOS assessment is a clinical decision at
the nursing home level, and in many instances, is of little value in the
care of the terminally ill hospice patient electing hospice.
b) Patient Change of Condition:
Various elements of the nursing home MDS/RAI relate to the progression
of the terminal illness and/or dying process. When supported by hospice
philosophy and experience, elements subject to a change in condition are
divided into three categories, detailed below. Guidelines to govern the
decision-making process for determination of whether a new MDS is to be
generated are outlined in the following paragraphs.
|
Potential expected outcomes of the
progression of the terminal illness and/or dying process
|
Delirium
Use of psychotropic drugs
Pressure ulcers
Dental care
Urinary incontinence (including catheter)
Behavior Problems
Falls (patient at risk for)
Cognitive loss/dementia
Communication
|
|
Expected outcome of the progression of
terminal illness and/or dying process
|
Dehydration and fluid maintenance
Psychosocial changes
Activities of daily living (ADL)
Mood status
Activities
Nutritional status
Visual function
|
|
Specials
|
Physical restraints
Feeding tubes
|
c) Potential, Expected Outcomes:
Certain changes in patient condition are potential, expected outcomes
of the progression of the terminal illness and/or dying process. That
is, while they may not be present in every terminally ill or dying
patient, these changes are not unexpected and are routinely
addressed by hospice staff in the regular course of care. The occurrence
of one of these changes should not trigger a change of condition MDS if
the change is related to the terminal illness and/or dying processes, is
anticipated and is documented.
The value of the information generated through a change of condition
MDS may be of very limited value in reshaping care provided to the
terminally ill or dying patient.
At the time a change in condition presents in the hospice patient
residing in the nursing home, a determination should be made as to whether
the change is related to the terminal illness or dying process, and
whether it has been documented. If so, a new MDS would not be triggered.
Instead, the hospice interdisciplinary team in collaboration with the
nursing home would address the change of condition through
the plan of care.
The federal RAI
manual (exit DHFS), page 2-11, provides the following guidance.
"In an end-stage disease status, a full reassessment is optional,
depending on a clinical determination of whether the resident would
benefit from it. The facility (nursing home) is still responsible for
providing necessary care and services to assist the resident to achieve
his or her highest practicable well being. However, provided that the
facility identifies and responds to problems and needs associated with the
terminal condition, a comprehensive re-assessment is not necessarily
indicated."
In evaluating the change of condition, the elements of the change as
set out in Appendix R, Resident Assessment Instrument for Long Term Care
Facilities, of the CMS State Operations
Manual
(exit DHFS)
should be reviewed by the
nursing home staff with the hospice staff. This process will necessarily
involve the expertise of the nursing home staff and underscores the
importance of the review being a joint effort.
The focus of the review is based on the resident’s condition
regardless of the cause. The following grid provides sample statements
that include the minimum elements to be reviewed under each RAP problem
area listed. Additional elements for review should be included based
on an assessment of individual patient circumstances.
|
Delirium |
Assess medication, psychosocial state and sensory loss. |
|
Use of Psychotropic drugs |
Assess medications (drug review) and side effects. Adjuvant drug
therapy will be utilized to provide palliative symptom management.
The risk-benefit ration evaluation regarding drug initiation and
continued use, including use outside the guidelines, will be
assessed by the hospice IDT/IDG and nursing home staff.
Documentation will be recorded in the clinical record by nursing
home staff. |
|
Pressure Ulcers |
Assess pressure versus stasis ulcer, assess skin integrity. |
|
Dental Care |
Dental care to increase comfort may be undertaken; preventative
dental care is not an expected part of the plan of care. |
|
Urinary Continence (including catheter) |
Reduced output may occur given the progression of the terminal
illness and dying process. Assess UTI, fecal impaction, UA,
diabetes, medication. |
|
Behavior Problems |
Assess volatility of mood, medications, and cognitive status. |
|
Falls (patient at risk for) |
Safety issues can be anticipated because of physical
deterioration with a terminal illness and associated adjuvant drug
therapy. Assess medications, appliances and environment. |
|
Cognitive loss/ dementia |
Assess functional limitations, sensory impairment, medication
involvement factors, and failure to thrive. |
|
Communication |
Assess components of communication, including strengths and
weaknesses, and medication. |
Terms:
IDT - Interdisciplinary Team
IDG - Interdisciplinary Group
UA - Urinalysis
UTI - Urinary Tract Infection
d) Expected Outcomes:
Certain changes in patient condition are expected outcomes with a high
probability of occurring as part of the progression of the terminal
illness and/or dying process. There are no identifiable benefits of
triggering a change-of-condition MDS on these criteria, provided that the
hospice and nursing home staffs have (1) jointly reviewed the criteria and
determined that the change of condition is linked to the terminal illness
and/or dying process, and (2) this review and determination have been
documented in the clinical records.
Seven of the RAP problem areas are expected outcomes of the progression
of the terminal illness and/or dying process. The following sample
statements address the respective RAP problem area listed.
Changes in hydration status and fluid balance occur as part of the
progression of the terminal illness and/or dying process. If the
change noted in the patient is related to that progression, the
benefits of generating a change-of-condition MDS are minimal in terms
of patient care, and do not outweigh the intrusion of conducting the
MDS.
Psychosocial changes - Changes in
lifestyle and interactions occur as part of the progression of the
terminal illness and/or dying process.
Activities of daily living (ADL) - The
hospice patient residing in the nursing home generally becomes
increasingly dependent on assistance with his or her activities of daily
living as part of the progression of the terminal illness and/or dying
process.
Mood states - The person experiencing a
terminal illness, from diagnosis to death, is anticipated to have
emotional fluctuations.
Activities - A decrease in or
non-involvement in activities is an expected outcome of the progression
of the terminal illness and/or dying process.
Nutritional status - Declining
nutritional status with progressive weight loss is expected in a
terminal illness.
Visual functions - A decrease in visual
function is anticipated with the dying process.
e) Special circumstances:
Changes in patient condition that present the potential need for
feeding tubes or physical restraints warrant special consideration. These interventions may have potential expected outcomes when utilized for
residents with progression of the terminal illness and/or dying process;
and they are of such a nature as to merit different elements of review.
Physical restraints, of the least
restrictive type, appropriate to the resident, may be used only under
the order of a physician. If used the restraint must enable the resident
to maintain his or her highest level of functioning. Restraint usage
must be consistent with the guidelines set forth in the CMS State
Operations Manual and state/federal nursing home/hospice regulations.
Refer to the clinical Guidelines distributed via DSL-BQA-00-021
memorandum related "Quality Improvement
Information: Providing a Quality Life While Avoiding Restraints"
(PDF, 497 KB).
These Guidelines are available on the DHFS web site at: http://www.dhs.wisconsin.gov/rl_DSL/NHs/NHnodMemos.htm
Feeding tubes - A normal part of the dying process is the body’s
decreased need and the patient’s decreased desire for nutrition and
hydration. The hospice is responsible for discussing the use of feeding
tubes with the patient/family as the terminal illness progresses and
will initiate enteral/parenteral feeding at patient/family request as
consistent with the philosophy of the individual hospice. Nursing home
staff is involved to the extent that the hospice would routinely utilize
the patient’s family/caregiver in the provision of enteral/perenteral
feedings.
If the need for use of physical restraints or feeding tubes is driven
by the progression of the terminal illness and/or dying process, the task
force believes that these changes should not alone trigger a change-of-condition MDS.
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