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Decreased compensation, withdrawn, life review, poor appetite.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