hospice nursing clinical primer...hospice terminology terminal prognosis 2-6 months out – hospice...
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Hospice Nursing Clinical PrimerIntroduction and Roundtable Discussion
Clinical Primer - Overview
Medicare Hospice Benefit Diagnosis vs Prognosis
Election Periods / Billing
Hospice Terminology
End of Life (EOL) Disease and system progression
Medication OnePoint Pharmacy & PBM
Provider Orders Paper forms
Hospice-focused Validated Tools & Topics Managing Acute Interventions
Meeting Responsibilities
HealthCareFirst (HC1) Documentation: best practices
and requirements
“I have learned Hospice is more about Quality of Life than it is
about death.”-- Pinterest ;-)
Medicare Hospice Benefit
Medicare as Payor Source: Hospice Benefit Part A Other Payor Sources: VA, Private
insurance, Medicaid, charity Medicare Part B: Provides
opportunity for PCP and continued treatment of non-hospice needs
Prognosis vs Diagnosis Global Functional Decline Primary Diagnosis, eligibility, ICD-10
Coding
Billing Election Periods: First 90 day, 2nd 90
day, and unlimited 60-day periods
Billing Changes in LOC (Discharge,
revocation, transfers) do not affect patient clinical care, but do affect back office billing and reimbursement
LOC reimbursement related to Four Levels of Care
Medicare ADR Process (Additional document review)
HealthCareFirst (HC1) “P Page” & Medicare Hospice regulations
Visits & Timing last 7 days of life
Sitting vigil
Visit frequency based on need: comfort r/t pain, nausea, agitation
Reimbursement change last 7 days
Hospice Terminology
Terminal prognosis 2-6 months out – Hospice
appropriate / Terminal 2-6 weeks from death – Transition
Decreased compensation, withdrawn, life review, poor appetite.
1-10 days from death – Active Poorly responsive, not eating, sips fluids, skin changes, sleeping and disorientation increase
Comfort Care instead of Curative therapy Palliative Care = Comfort care
Medicare & Hospice Language Levels of Care (LOCs) Forms
BLOC (Billing Level of Care)
NOMNOC (Notice of Medicare Non-coverage)
PASRR (Pre-Admission Screening & Resident Review program)
MOST (CO Medical Orders for Scope of Treatment)
MDPOA (Medical Durable Power of Attorney)
5 Wishes (living will)
Misc Advanced Directives
End of Life (EOL) Disease and System Progression Research patterns of disease progression & Systemic impact by diagnosis
Cardiac / CHF, Hypertensive Heart Disease with Heart Failure, Coagulapathies
COPD / Pulmonary Fibrosis / Interstitial Lung disease
Cancers
ESRD – End Stage Renal Disease
Dementia: Alzheimer’s, Lewy Body (Parkinson’s), Cerebral Atherosclerosis
Wounds / Bones
Infection: UTI, Skin, PNA
Diabetes – Glucometrics
Colorado End Of Life Options
Hospice Medication EOL medication philosophy & formulary
what is covered under Hospice Benefit
Symptom management tools / Pharmacist assistance
Non-covered medication approval determination process
QMAPs (Qualified Medication Administration Personnel)
Suncrest Nurses may administer medications in facilities and homes (exception: May not administer End of Life Option medication)
Admission / new patient de-prescribing: vitamins, pills, anti-coags, treatment meds, dementia meds, poly-opiate pharmacy
EOL Medication Titration Hospice MD as resource Pharmacist
Comfort Kit – Primary Hospice meds Pain/Respiratory Distress: Morphine Sulfate /
Roxanol (20mg/ml)
Terminal agitation: Haldol drops
Anxiety/Agitation: Ativan tabs/drops
Nausea: Compazine suppository
Fever: Acetaminophen suppository
Secretions: Atropine drops (give orally, not opthalmically)
Filling Syringes / pre-filled syringes
Delivery: stat vs scheduled Usually 2 weeks delivered per order
C2 orders valid for 2 months of refills, all other meds valid for 3 months of refills
Medication Disposal Facility vs home
Disposal kit
Next of kin own deceased’s meds in Colorado
EOL Option Meds: Return to PCP or Drug Take Back. Hospice nurses may not touch/assist.
Orders Written orders: checking in
and out Attending PCP first option for
orders Orders in Multiple Locations:
Facility, HC1, PCP, written copy, OnePoint
Facility order Protocols: volume vs dosage, crush orders, plain English writing, using Facility order sheets (usually SNFs)
PRNs in facilities / memory care
PCP vs Hospice MD Oxygen Orders (standing and
individual orders & equipment)
Paper Orders: signed C2 Order form
Only for opiates and other C2 medications (does not include lorazepam or haloperidol).
Write orders sufficient quantity to be valid for up to 2 months for hospice refills. C2 Medications must be written and faxed c signature to OnePoint or prescribing pharmacy
Comfort Kit Order form May make minor modifications based on facility PRN
and Haldol requirements.
If ordering meds individually or with customized administration orders, use TO/VO and C2 forms.
TO/VO – Telephone/Verbal Order form Signed orders for general order use, medications,
wound care orders, admission and death/discharge orders, specific facility orders, etc.
Non C2 medications may be verbally provided to OnePoint. Non C2 medication orders valid for 3 months of refills.
Hospice-focused Validated Tools & Skin Care PPS: Palliative Performance Scale. Global
functional indicator (use for all patients). Online at https://eprognosis.ucsf.edu/pps.php
FAST: Functional Assessment STaging of Alzheimer’s Disease. Functional deterioration. Only for AD type dementia. Always use for AD, even if not primary diagnosis.
MAC: Mid-Arm Circumference. Nutritional status/muscle wasting. Measured around bicep mid-way between distal end of humerus (olecranon process) and acromion. With arm hanging straight down, measure in CM to nearest MM.
ADL’s: Activities of Daily Living. Measure of decline. Eating, bathing, dressing, toileting, transferring, continence care.
Weight: in pounds (LBs). Nutritional Status.
Braden Scale: Predictor for pressure sore risk. < 13 is high risk.
Kennedy Terminal Ulcer (KTU): Potentially unavoidable pressure ulcer developed by some during dying process Unlike Pressure Ulcers, KTU’s have sudden onset
(hours to days)
Rapid progression: from blister or Stage II to Stage III or IV
Theorized to be related to hypo-perfusion with multi-system organ failure
Usually sacrum/coccyx (also seen on heels, calves, elbows)
Poor prognosis
Skin Care Skin Protectant: A&D ointment with lanolin and
petrolatum and non-medicated Lotions. CNAs may apply. Should be noted in Hospice Aide Care Plan B (HACPB).
Barrier Creams (with Zinc and/or Dimethicone). Requires an order, Suncrest CNAs may not apply.
Anti-Fungal products. Requires an order, Suncrest CNAs may not apply.
Wound Care Comfort-focused and accessible treatments,
consider staff availability
Additives & Cleaning: Wound Cleanser: for all wound staging, mist or
stream to loosen / remove protein and wound debris
Skintegrity hydrogel: for dry-to-moist wounds, creates moist wound environment, may be left up to 3 days, not considered antimicrobial, donates moisture, rinses easily
Barrier Creams: Zinc & Dimethicone (require orders)
Silvasorb/silver: antimicrobial barrier for dry and lightly draining wounds, fluid management, gel may be left up to 3 days
TheraHoney/therapeutic sterilized honey: maintains moist environment, promotes autolytic debridement via osmotic pressure, reduce pH.Sheets porous and allow passage of exudate, reduces odor.
Arglaes: Antimicrobial powder, may be left up to 5 days, for light-t-heavy drainage wounds,
Hydrogel – donates moisture, all wound stages
Dressing & Moisture Balance Optifoam (Gentle): gentle adhesion, breathable, highly
absorbent, waterproof outer layer,
Optilock: ideal for highly draining venous leg ulcers, gentle contact layer, fluid-locking, can be combined with CoFlexbandages, may leave up to 7 days
Maxorb / alginate: combine with Optifoam/bordered gauze, excellent absorption and fluid management, may be left up to 7 days. Maxorb Ag adds antimicrobial protection and may be left up to 21 days
Exuderm: primary dressing, manages drainage, wear time up to 7 days, occlusive barrier
Versatel One – reduces secondary dressing wound adherence, provides fluid transfer
Sureprep – skin protectant, protects from adhesive stripping, creates waterproof barrier on periwound skin, protects from friction & fluids
Unna Boots: gauze dressing with Zinc, provides moist healing environment, may be left up to 7 days, provides light compression, usually covered by cohesive bandage (CoFlex)
Medigrip: Tubular bandages, provide joint support, may be reapplied, good for securing dressings, may provide mild compression, may be left up to 7 days
Infection/Inflammation: use Maxorb Ag+, Optifoam Ag+, Silvasorb, Arglaes Powder
Debridement: TheraHoney. Pair with absorbent dressing
Acute Intervention Management Never Never, Never Always
Each situation unique and deserves a flexible and individualized approach
Collaborate with supervisory team to determine best path and potentially covered treatments
ER Visit management Advocate for patient and family. What are the goals?
Review Suncrest Hospice ER Visit Protocol
ER/Hospital visits challenging for elderly and patients with dementia.
Limit non-productive tests / interventions
Revocation options, timing, and resources including Social Services team
Common goals: return home, comfort-focused treatment
Aggressive treatment alternatives: treat symptoms, not diagnoses IV fluids and antibiotics – when preference should be to
avoid and why (3rd-spacing, possible pain and consideration for restraints when using IVs in hospital)
Surgery, Trachs & G/J-tubes – purpose & outcomes vs patient and family wishes
Wound care, wound vacs, debridement & antibiotics: comfort focused, not necessarily curative
Tests & Labs Use Hospice MD to determine appropriateness of
invasive and cumbersome testing
UAs – treat symptoms, not infections. If symptomatic, let’s improve quality of life. E.G. common chronic UTI colonization may not require treatment if not symptomatic.
CBC/CMP – Occasionally ordered c other labs when potential exists to support Hospice prognosis, likely run during initial ER visits
Glucose – often reduced or discontinued. When continued, primarily treated as non-Hospice diagnosis by PCP / Facility for chronic mgmt
Coags (Pt/INR) – Encourage de-prescribing as appropriate
may cause increased bruising, bleeding, anemia, and internal hemorrhage (8% chance)
Benefit? Only minimally reduces stroke risk in patients with a-fib (from 2% to 1% in 6 months)
X-rays, CT & other scans
Ask about benefits: what interventions are likely as a result? Should patient go to surgery, or go home? Is it okay to spend thousands of dollars “just to know” if there’s no likely intervention?
RN Assessment Equipment and Supplies
Assessment Equipment Provided by Suncrest Hospice:• Thermometer• Measuring Tape• Computer / Tablet• Pulse Oximeter• Precaution gear (standard, contact)• Medication Disposal Kits
Not provided by Suncrest Hospice:• BP Cuff / device• Stethoscope
Initial Nurse Supply Checklist Wound Care
Catheter Care
Skin Care
Incontinence Care
PPE
Miscellaneous
Handout: Supply Checklist
Nursing Meetings IDT Meeting (Interdisciplinary Team Meeting)
Weekly, required Purpose: fulfills Medicare Conditions of Participation requirements, regularly
review Plan of Care for all patients, collaborate c peers on non-acute issues Patient care comes first, communicate with Supervisor
All Nursing Meeting Monthly, required Communicate c Supervisor if unable to attend Purpose: provide clinical and administrative updates and education,
collaboration with nursing team
Clinical Staff Meeting Bi-Monthly, required (communicate c Supervisor if unable to attend) Purpose: Collaborate and learning in joint meeting of Nursing & Social Services
teams
HealthCareFirst Documentation ReviewOverview & Best Practices
Logging In & using Education Site Finding patients, Demographics and
Address information Searching for Documents & Orders Chart Tabs: Face Sheet, Relationships,
Care Profile, Orders, Documents Lock & Complete, Alerts When to open documents “P” Page Visits: PRN, NVN, INA Updating Records: Add new or
Discontinue, do not edit, delete or change. Examples: addresses, LOC, Medications, Election Periods, PCPs.
Documents with data that “flows” to next document: INA, NVN, IDT POC Update
Organizing patient information with electronic or written report sheet
Primary Documentation NVN, PRN, HASVN, HACPB, RPOC, IDT POC
Updates, DVN, Fall Risk Assessment, Braden Scale, PPS, Case Communication, Discharge Summary, Imminent Status Review
Admissions Primary Documentation: INA, IPOC, IDT POC, Case Communication
Charting to Decline: Focus on appropriateness for hospice based on primary diagnosis and global prognosis
Discharging a Patient: Select “Discontinue & Cancel” button, fill in nurse portion of Discharge Summary, condolence calls
Orders & Visit Orders: IDT Frequency, PRN, medications, wound, misc
Accidentally opened orders and documents: notify Supervisor