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Hospice Care Inc. places its nurses in home care
The trials and tribulations of your home care counterparts are well-documented. Changes in their payment structure place them in a position to improve continuity of care as they begin moving toward per-episode care.
But change allows for opportunity. Hospices have traditionally suffered from short lengths of stay and struggled to come up with ways to bring patients into its care sooner. Because hospices encounter higher costs in the first few days following admission and in a patient’s final days, per-diem payments are often not enough to cover the cost of program introduction at admission and intensive care at the end of a patient’s life.
With the move from per-visit payment, home care’s incentive is to look at episodes of care with some agencies needing to have shorter stays.
Hospice Care Inc. in Stoneham, MA, may have come up with a solution that helps achieve shorter home health stays and increase hospice stays — using hospice nurses in the home care setting to help facilitate a quicker transition into hospice care.
"For the first time, home care has an incentive to control the patient stay," says Kate Colburn, MA, executive director of Hospice Care, a home hospice provider. "[Home care agencies] need to have shorter stays. This complements hospice, which wants its stays to increase."
Reducing money problems
With its median length of stay at 14 days and its average length of stay 41 days, Hospice Care’s dwindling length of stay is typical of the hospice industry. The two most intensive periods of care — program introduction and patients’ final days — were overlapping, eating up more money than their Medicare per-diem payment provided.
According to Colburn, if the new program is successful, it will increase their median length of stay to 20 days and may reduce the hospice’s dependence on donated funds.
To reach its goal, Hospice Care fashioned an arrangement with a local home care provider that calls for the home care agency to subcontract a hospice nurse to provide home health care to the agency’s patients on a per-visit basis. The hospice/home care nurse — aside from delivering visits on behalf of the home care agency — can help educate patients and their families on the benefits of hospice.
The process begins at the assessment stage, held during home care admission. Patients admitted with potentially terminal illnesses are cared for by Hospice Care nurses, who are paid on a per-visit basis.
By using a hospice nurse in a home care setting, the patient is given the opportunity to forge a relationship with a nurse that could potentially carry into the hospice setting, says Colburn.
One of the struggles hospices face in order to increase length of stays is an unwillingness to move into another health care segment out of fear of losing the special relationship the patient has forged with members of the home care team, Colburn says. The prospect of a new care discipline and a new set of caregivers, no matter how comprehensive or compassionate, can be unsettling to those who have come to rely upon the care and kindness of the home health providers.
"Patients don’t want to lose the two people that they have developed a close relationship with, " Colburn says. "Once they move into hospice, they continue their relationship with their home care team and gain new members through the interdisciplinary team, each of which sees the patient for assessment."
Putting the model to work
To further promote the continuity of health care providers, Hospice Care will also subcontract the home health aide from the home care agency to provide services after the patient is referred to hospice.
"This way, they don’t lose the two people that they have developed a close relationship with. When they are readmitted to hospice, they gain the additional members of the hospice [interdisciplinary] team," says Colburn.
Although the model encourages earlier home health care discharge into appropriate hospice care, one home health provider sees this arrangement as an improvement in patient care more than an arrangement that enhances efficiency.
"This is about improving continuity of care, enhancing care, and sharing skill sets," says Patricia Demers, RN, MS, MPH, executive director of Winchester Home Care in Winchester, MA.
Winchester Home Care is the first home care agency to sign an agreement with Hospice Care to share nurses and home health aides.
While Colburn sees her model as being one that can be adopted by most hospice and home care agencies across the country, she admits that it isn’t as simple as it sounds.
To begin, Colburn says the transition model should be implemented by a hospice and a home care agency that already have a solid working relationship. Aside from the obvious reason of trust and collegiality, those that already have a track record can use past experiences to determine which home care admissions call for the use of a hospice nurse.
"What hospices ought to do is focus on one or two [home care] organizations that they are comfortable with," Colburn says, "and start with specific types of diagnoses, such as cancer."
How to make the partnership work
Although both hospice and home care agencies have worked well in the past, the Hospice Care model requires both sides to enter the realm of their colleagues and understand the demands and constraints of their partners.
In order for the partnership to work, clinical workers on both sides must be trained in home care and hospice requirements. Although clinical care will not vary too widely, documentation and required forms for reimbursement will.
For that reason, hospices nurses must undergo training and orientation in home care documentation and become familiar with the home care agencies’ required forms for reimbursement.
On the other hand, home care personnel must be trained to spot cases that have the likelihood to lead to hospice care. To facilitate the learning process, Colburn recommends sharing local medical review policies (LMRP) with their home care partners so they have a clear understanding of what Medicare and their fiscal intermediaries require before a patient can be referred to hospice.
The hospice and home care agency will likely rely on experience to show which patients have the potential to be moved into hospice care. A review of charts will often reveal a pattern. Certain diagnoses will more often lead to hospice referral than others. Sharing LMRPs with the home care agency will help them better prepare for admission and trigger the use of a hospice nurse to facilitate an earlier referral to hospice care.
Hospice nurses and home health aides are required to participate in 16 to 21 hours of orientation training, where they learn the clinical policies and procedures of the organization they will be working for on a contractual basis. As part of the training, each is familiarized with the required paper work of each organization and schooled in proper documentation.
The element of cross-education and sharing skills is what attracted Demers to the Hospice Care model.
"If you have someone who works in hospice and can teach it, it will be easier to sell. Hospice is hard to sell, especially to physicians," she says. "Hopefully, we can help people understand. When I think of programs like this, I think of the Peace Corps, where you teach people how to be successful."
The elements of cross-education and sharing skills are what attracted Winchester Home Care to the Hospice Care model. Still, Demers warns that the model is not for every patient that is identified as a potential hospice referral.
"But for specific patients," she says, "the transition in hospice care will come earlier and provide additional resources and counseling."
Although both sides are providing services to the other, there is no exclusive arrangement, especially in the area of referrals. It is important to note that hospice nurses educate patients and families about hospice care prior to hospice admission; education includes providing a list of all hospices in the area, allowing patients to choose from a number of providers that include Hospice Care Inc.
For now, the Hospice Care model is an experiment. Colburn says she hopes to collect a year’s worth of data to track the length of patient stays and measure improvement in continuity of care.
Beyond the numbers, however, Hospice Care and Winchester Home Care hope to prove that despite the challenges facing both their industries, partnerships like theirs can address the needs of all their customers, including the patient, Medicare, and each other.
The patients benefit because they are given information and choice about hospice when their condition makes hospice care appropriate. They are transferred in a manner that does not interrupt the care team they have grown to trust. Medicare is served by moving the patient along the health care continuum appropriately.
Ultimately, hospice and home care learn more about each other as they strive to create a seamless transition for their patients.