Partnership in End-of-Life Care
Donna S. Williamson, BSN, RNC, CHPN
Palliative Care Consultant/LTC Facilitator
Mountain Home, Arkansas
Identify the benefits of developing a nursing
facility/hospice partnership.
 Assess whether care is being provided
according to regulations.
 Explain the steps in developing a coordinated
care plan.
 Identify the steps in implementing the care
plan.
 Identify problematic areas in developing a
coordinated care plan.
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What are your opinions of this
NH staff?
Hospice staff?
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Caregiver is inadequate
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Caregiver is absent
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Environment is unsafe
There is no provision in the Hospice Benefit for a
primary caregiver.
The nursing facility can provide ‘room and board’
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Physical symptoms are not controlled
 Resident is in a non-skilled bed
 Resident does not want to leave the facility
 Resident does not want aggressive care
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Psychosocial issues exist
 Family in crisis
 Other residents grieving
 Facility staff grieving
“There is no indication in the statute that the
term ‘home’ is to be limited for a hospice
resident. A resident’s home is where he or she
resides. The facility is considered to be the
beneficiary’s place of resident (the same as a
house or apartment), and the facility resident
may elect the hospice benefit if he/she also
meets the hospice eligibility criteria.”
 Section 2082, State Operations Manual
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Validation of care by an outside provider
◦ CMS Quality Indicators are negative
outcomes
◦ Prevalent in the dying process
◦ Two of the three sentinel events are
common problems in the terminally ill
resident.
 Dehydration
 Fecal impaction
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Supporting Documentation
◦ Hospice consent form: Resident elects to
receive palliative care.
◦ Physician terminal prognosis.
◦ Advance directives.
◦ Hospice team charting on quality
indicators.
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Hospice expertise
◦ Symptom control
◦ Psychosocial intervention
◦ Spiritual care
◦ Bereavement
◦ Resident and family support
◦ Dealing with ethical issues
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Nursing Facility Surveyor Guidelines
Hospice Guidelines
Fraud & Abuse Alert
Hospice Compliance Program
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Resident elects hospice benefit
Hospice RN makes an initial visit performing
complete assessment
Review physician orders to align with
palliative care plan
Review assessment with MDS Coordinator and
begin development of care plan
Sharing of Care plans
Joint care plan coordination
Document collaborative care planning
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They are either...
◦ A new admission to the facility
OR
◦ A pre-existing resident
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Hospice must complete the assessment and
care planning process within 48 hours upon
admission.
Nursing facility has 21 days.
Hospice can share hospice problem list and
care plan with MDS Coordinator.
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Nursing facility has completed MDS & Care Plan.
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Complete a Significant Change in Condition form.
◦ Prognosis of six months or less
◦ Changed from acute to palliative care
◦ No need to fill out future significant change forms as
resident’s condition deteriorates
◦ MDS triggers a new problem list
◦ New care plan reflects palliative care
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Develop a common problem list
All triggered problems do not require care
planning
Problems may be identified that are not
triggered
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State Operations states:
◦ “coordinated plan of care for both providers reflects
hospice philosophy.”
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Conditions of Participation for nursing facility
states:
◦ “the resident receives care and services to attain or
maintain the highest practicable physical, mental
and psychosocial well-being.”
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Most Common source of tension and
confusion in the relationship.
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Self-Determined Life Closure
◦ Anticipating death, mentally competent residents will
have full autonomy to make decisions about how the
remainder of their life is spent within the allowances of
law.
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Safe and Comfortable Dying
◦ The resident will die free of distressing symptoms, in an
environment that does not aggravate or hasten dying.
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Effective Grieving
◦ The expression of grief eventually supports the
individual’s ability to adjust to their environment
without the deceased & regain the ability to invest in
other activities and relationships.
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After the comprehensive assessment
process is completed, the interdisciplinary
team will be able to decide if…
◦ The resident has a troubling condition that
warrants intervention, and addressing this
problem is a necessary condition for other
functional problems to be successfully
addressed;
◦ Improvement of the resident’s functioning
in one or more areas is possible;
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Improvement is not likely, but the present
level of functioning should be preserved as
long as possible, with rates of decline
minimized over time;
The resident is at risk of decline, and efforts
should emphasize slowing or minimizing
decline, and avoiding functional
complications (e.g., contracture or pain) or;
The central issues of care revolve around
symptom relief and other palliative measures
during the last months of life.
Resident
Provision of Care Services
Outcomes
Negative
Avoidable
Unavoidable
Positive
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Reflect Hospice philosophy
Designate responsible provider
Designate responsible discipline
Establish when it will be done
Change and update to meet the resident’s
needs
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“Substantially all hospice core services
(physician services, nursing services, medical
social services, and counseling) must be
routinely provided directly by hospice
employees and cannot be delegated.”
“The hospice may involve the SNF/NF nursing
personnel in assisting with the administration
of prescribed therapies included in the plan of
care only to the extent that the hospice would
routinely utilize the services of a hospice
resident’s family/caregiver in implementing
the plan of care.”
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Room and Board Services include:
◦ Performing personal care service
◦ Assisting with activities of daily living
◦ Administering medication
◦ Socializing activities
◦ Maintaining cleanliness of a resident’s room
◦ Supervising and assisting in the use of
durable medical equipment and prescribed
therapies
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Requires the Professional Management of:
◦ Services of the Interdisciplinary Team
◦ Medication related to the terminal illness
◦ Medical supplies related to the terminal
illness
◦ Durable medical equipment
◦ Lab, x-ray, treatments, etc.
◦ Inpatient care for periods of crisis
 Resident does not have access to Medicare Part
A services and has limited access to Part B
services
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Follow the steps of the nursing process
Remember…Outcomes are clinically
“unavoidable” only if…
◦ Accurately assessed
◦ Adequate care is planned
◦ The care plan is actually implemented
◦ The interventions are evaluated
periodically and modified according to the
resident’s responses.
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Documentation in the MDS for Resident #2, noted
the resident to have a short and long-term memory
deficit and moderate impairment of cognitive
function.
Record review identified the resident was being
seen by a psychologist for individual therapy three
times weekly for behaviors.
The resident was also being seen by a psychiatric
consultant for management of her behaviors and
antipsychotic medications. The resident is not
cognitively aware to receive and participate in this
therapy.
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Resident #1
◦ This resident is obese and has congestive heart
failure, cellulitis, edema, and stage-3 pressure
ulcers.
◦ According to the outcomes of the care plan, she has
nothing to worry about because all these problems
are going to be controlled or reversed.
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Resident #2 – This resident is mentally
retarded and has just undergone a colon
resection for advanced colon cancer.
◦ Problem: Alteration in thought process, impaired
decision-making, impaired cognition secondary
to diagnosis of mental retardation.
◦ Goal: Resident will be able to make safe and
reasonable decisions regarding care needs with
the assistance of staff through next review
◦ Intervention: Encourage resident to discuss
reasons for inappropriate decisions and how they
can be avoided in the future PRN.
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Resident #3-This resident has cancer of the
brain and is having seizures
◦ Problem: Weight is above ideal weight.
Family and resident are often noncompliant with diet. PO intake varies.
◦ Goal: Resident will be free of weight gain
from weight of 228 lbs. by next review.
◦ Interventions: Sugar substitutes, skim milk
with meals, encourage family to bring in
healthier low-fat snacks.
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Resident #4-The care plan reads: Notify
hospice, without any other interventions for
the hospice team.
Resident #5-This care plan has a hospice
portion that is stapled to the nursing facility
care plan.
◦ Goal: Provide a safe and comfortable environment
conducive to the death and dying process in
which the physical, spiritual and psychosocial
needs and symptoms will be addressed and
resolved, and resident will die in a supportive,
care-giving system in accordance with their
wishes.
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Regulator/Surveyor
Fiscal Intermediary
Nursing Facility
Resident
Family