Denise Winzeler​Although skilled nursing facilities (SNFs) are experts at caring for the elderly, some aspects of end-of-life care may present challenges beyond their usual expertise. Yet, when attending to the elderly, end-of-life care will inevitably become necessary at some point. Providing this support may be difficult due to lack of knowledge, staffing issues, or because staff love the resident like a family member. Fortunately, facility staff don’t have to do this alone. Hospice organizations are experts at end-of-life care and can strengthen the team during this time, benefiting the resident, their family, and the facility.

Why Collaborate with Hospice?

Collaboration with hospice has many benefits. For residents and family members, hospice staff are adept at having hard conversations. They are familiar with palliative care options and have experience discussing end-of-life decisions. Incorporating hospice can help all parties involved make a smooth transition, feel at peace with decisions, and assure family members their loved one is comfortable in their last days. Facility-hospice collaboration can provide care as the resident and family define it, delivering a higher level of care to the resident in a familiar environment.

Collaboration can also greatly help the nursing facility. Benefits to the facility include:

  • Resources for education on topics like pain management, advanced care planning, behavior management, and death-and-dying principles
  • Hospice-certified nursing assistants to provide ADL care
  • Staff to sit with a resident if one-on-one care is needed
  • Provision of medications and supplies related to the hospice diagnosis
  • Reduced hospital admissions
  • Expertise in pain and symptom management

Barriers to Collaboration

Collaboration between organizations always has some impediments, but the key to getting past these barriers is communication. Cultivating that communication starts with education. Facility staff should be educated on topics like:

  1. What hospice is and what services hospice provides
  2. What regulations must be followed when collaborating with hospice
  3. What roles each entity plays
  4. When to refer a resident to hospice
  5. How to contact hospice
  6. Principles of death and dying

Conduct additional education as needed for areas such as pain management and advanced care planning. Unfortunately, myths surrounding hospice persist. Dispel confusion by also educating facility staff on the following myths:

  • A resident must bet them from receiving hospice benefits, and a particular status is not required for hospice care. However, there does need to be a conversation between hospice and the resident and family to clarify their wishes regarding resuscitation.
  • A resident receiving hospice benefits cannot transfer to the hospital. A resident on hospice may transfer to the hospital after hospice evaluates them and agrees the resident needs to be transferred. Remember that hospice is the manager of the resident’s care. The resident can also elect to drop the hospice benefit i
  • A resident receiving hospice benefits cannot receive therapy services. The resident’s care plan drives all services. If functional ability can improve or be maintained through therapy services, hospice will agree to these services. Usually, these services are provided on a short-term basis and will be evaluated for need every few weeks.
  • A resident receiving hospice benefits cannot have labs or x-rays. The resident’s care plan drives all diagnostic tests. If the test will enhance care, then hospice will agree. Hospice frequently uses diagnostic tests to sup

The facility is penalized if a resident does not pass away within six months of electing hospice benefits. No one can determine when a person will pass. The burden of providing documentation to support the terminal diagnosis is hospice’s responsibility, not the facility’s.

Hospice speeds up a resident’s death. Hospice care neither hastens nor prolongs the dying process. It does, however, make the resident as comfortable as possible during the process and improves the quality of life.

MDS and Quality Measures

A significant change Minimum Data Set (MDS) must be completed within 14 days upon election of hospice benefits, transfer of hospice providers, or dis-enrollment of hospice benefits. A resident on hospice can also affect the facility’s Quality Measures. If the MDS is coded that the resident is receiving hospice services, then the resident is excluded from the calculations for the following Quality Measures:

  • Percent of residents who made improvements in function
  • Percent of residents who lose too much weight
  • Percent of residents whose ability to move independently worsened
  • Percent of residents who used anti-anxiety or hypnotic medications
  • Percent of residents whose need for help with activities of daily living (ADLs) has increased

Care Planning

Richard Russell, MBA, BSN, RN, CHPCA, President/CEO of Hospice of Northwest Ohio says, “The goal of hospice is to understand the expectations of the resident and their family and to work with the facility to devise a plan of care to address these expectations.” Collaborative care planning for residents receiving hospice services is of utmost importance and a focus of surveyors when they review records. Unfortunately, this is where many SNFs err and receive citations related to care planning under F849, F656, or F657. According to F849, the collaborative care plan should include:

  • Advanced directives
  • Provision of ADLs
  • Symptom management, including nausea control, agitation, pain, uncomfortable breathing, pressure ulcers, nutrition and hydration needs, and psychosocial needs

Care coordination with hospice and how to contact hospice 24 hours a day
Since the care plan is intended to be a collaborative effort, facility staff should invite the hospice nurse or hospice representative to join the care plan meeting; their expertise can help to formulate or revise a care plan. The facility should notify hospice of any changes to the plan, and vice versa.

Operational Responsibilities of the SNF

According to F849, the SNF must have a written agreement in place with the hospice organization before service provision, and that agreement must include:

  • Services the hospice will provide
  • Hospice’s responsibilities for determining the appropriate hospice plan of care
  • Services the SNF will continue to provide
  • A communication process, including how to document communication between the SNF and hospice, to ensure resident needs are met 24 hours per day

F849 further states that the SNF must designate a point person with a clinical background to coordinate the resident’s care plan and liaise between facility staff and hospice. Although not required by regulation, the written agreement should also stipulate billing practices.

Additionally, the facility should have policies and procedures regarding hospice care that address:

  • When and how to refer a resident to hospice
  • How facility staff notify hospice of changes, including a significant change in status, change in care plan, need to transfer the resident, or resident death
  • The process for physician order changes
  • How to request supplies and medications from hospice and what can be requested
  • How and when to report abuse, neglect, or mistreatment by hospice personnel

Facility leaders using the above tips, along with the CMS Hospice and End of Life Care and Services Critical Element Pathway, can better collaborate with hospice—and can provide residents and their families a more dignified and peaceful end-of-life experience.

Denise Winzeler, BSN, RN, LNHA, DNS-CT, QCP, is curriculum development specialist for the American Association of Post-Acute Care Nursing (AAPACN). She can be reached at