When to Call Hospice

When to Call Hospice

Hundreds of times each year, patients and families say: “We wish we’d entered hospice sooner.” Patients and families can benefit most from hospice care when they seek support earlier rather than in a crisis.

Will your physician tell you when it’s time for hospice?

Often times your physician is the first to mention the possibility of hospice care. Not always, however. Some physicians hesitate to bring up hospice because they sincerely want to preserve hope for a cure. Frequently, they will continue to pursue treatment because they think that’s what the patient and family want. In other cases, such as with congestive heart failure or lung disease (COPD), it may be difficult for them to predict the rate of a patient’s decline. When a doctor does mention hospice care, he or she is simply presenting an option for comfort, which in many cases may actually lengthen life by increasing the quality of the time remaining. It is important that you and your doctor talk openly and share the same goals for maintaining quality of life.

What are some signs that a person may be ready for hospice care?

  • An increase in pain, nausea, breathing distress or other symptoms
  • Repeated hospitalizations or trips to the emergency room
  • Failure to “bounce back” after medical set-backs occur
  • Decrease in function requiring assistance for walking, eating, bathing, dressing and/or going to the toilet
  • Decreasing alertness – patient is emotionally withdrawn, sleeping more or having increased difficulty with comprehension
  • Significantly decreased appetite and weight loss

What are some signs that our family could benefit from hospice?

Caring for yourself as your loved one’s caregiver is one of the most important things you can do. Front Range Hospice supports the family in conjunction with the patient. How do you know if you or your caregivers could benefit from hospice care?

  • You or your caregivers are physically and/or emotionally exhausted from caring for you or your loved one.
  • Your family is feeling isolated because of caregiving demands or the uncertainties you feel about your loved one’s future.
  • You or members of your family appear to need emotional support to cope with the sadness of the situation.
  • You are overwhelmed by the myriad of physical, financial, emotional and spiritual concerns arising because of the illness.

Can we call Hospice even if we don’t think it’s “time”?
Absolutely. An important part of our mission is providing guidance to families about any end-of-life care issue, whether or not they’re in our program. You don’t need a physician referral to call us for information. If it appears that hospice care would be beneficial, we will, with your permission, contact your doctor to discuss it.

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Terminal Prognosis

Terminal Prognosis

By Victor Montour

J. Donald Schumacher, PsyD, President and CEO of the National Hospice and Palliative Care Organization posted information on his website bringing attention to the importance of using terminal prognosis.

In his talking points he points out as providers of hospice care, we must reframe the way we characterize our patients. He goes on to say that we have to move away from using just one single diagnosis to using a more comprehensive list of diagnosis that utilizes all diagnoses and conditions that contribute to the patient’s terminal prognosis.

In 1983 the Medicare hospice benefit’s definition was written and in it, the definition of “terminally ill” has always included the term “medical prognosis”. This definition has not changed over the years. Most hospice providers have forgotten that eligibility for hospice has always hinged on a patients terminal prognosis.

Donald goes on to say that regulators and legislators are concerned that hospice providers may be falling into a pattern of narrowly defining a patient’s condition and we are failing to deliver the full array of services that hospice providers should be responsible for.

The NHPCO strongly feels that the hospice physician is the most appropriate professional to determine whether something is related to the terminal prognosis. Front Range Hospice has always listed a primary diagnosis for hospice care and all supporting diagnosis’s so we can focus on our patient’s terminal prognosis. Providing a full picture of our patient’s current medical condition gives our caregivers, families and hospice team the best opportunity to provide Legendary Care.

If you would like more information about Front Range Hospice or what is Terminal Prognosis, please call 303-957-3101 or 970-776-8080 or email us at info@frhospice.com

Watch out for our next blog: When to Call Hospice

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Hospice Care and Nursing Facility Relationships

Hospice Care and Nursing Facility Relationships
By Victor Montour

End of life care is critically important in the skilled nursing facility. A good hospice partner should play an important role in quality end of life care. The relationship between the hospice and the nursing facility must be defined by the medical needs of the patient.

The government is now taking aggressive action against hospices and nursing facilities that request or provide illegal compensation to influence referrals. Doing so is a direct violation of the federal anti-kickback statute (AKS) and the Federal False Claims Act (FCA). The government is now using both laws to identify, prosecute and penalize hospices and nursing facilities based on a wide range of practices that are viewed as providing incentives to the nursing facilities. Some of these practices may include.

  • A hospice providing staff at its own expense to the nursing facilities to perform duties that otherwise is performed by the nursing facility staff.
  • Hospices providing services at the request of the nursing facility instead of according to the medical needs of the hospice patient.
  • Nursing facilities requesting and hospices providing services that are not considered hospices services, such as around the clock non-skilled companionship type services.
  • Hospice offering or providing free goods or services to nursing home staff, such as gift cards or lunches.

The potential consequences of violating the AKS or FCA are immediate, severe and could threaten the continued viability of many nursing facilities and hospices. The government can suspend Medicare payments to nursing facilities and hospices if there is a “credible allegation of fraud” such as an alleged AKS or FCA violation. The nursing facility and the hospice that engage in practices that violate the AKS and FCA can be prosecuted and given severe penalties.

Hospices and nursing facilities are under increased scrutiny. Under the new regulations nursing facilities must ensure and be able to show that the services they provide to resident hospice patients are consistent with the level of care that would be provided before hospice care was started. We have seen at Front Range Hospice the annual survey process that nursing facilities receive from the state and how they are now including a detailed review of patients on hospice services.

Front Range Hospice works hard to eliminate the risk of becoming an AKS or FCA statistic by avoiding the practices described earlier in this blog and any other practices not mentioned that one could interpret as a violation of the AKS or FCA laws.

If you would like more information about Front Range Hospice or Hospice Care in a nursing facility please call 303-957-3101 or 970-776-8080 or email us at info@frhospice.com

Watch out for our next blog: Terminal Prognosis

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Attending Physician – You Have a Choice

Attending Physician – You Have a Choice

By Victor Montour

Hospice beneficiaries have the right to choose their attending physician. The patient has a right to exercise his or her rights as a patient of hospice which includes the right to choose his or her attending physician.

“Attending physician” is defined as a:

(1)(i) Doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he or she performs that function or action; or (ii) Nurse Practitioner (NP) who meets the training, education, and experience requirements.

(2) A physician identified by the individual, at the time he or she elects to receive hospice care, as having the most significant role in the determination and delivery of the individual’s medical care.

The election statement must include the patient’s choice of attending physician. The information identifying the attending physician should be recorded on the hospice election statement in enough detail so that it is clear which physician or NP was designated as the attending physician. The language on the election form should include an acknowledgement by the patient (or representative) that the designated attending physician was the patient’s (or representative’s) choice.

If a patient (or representative) wants to change his or her designated attending physician, he or she must follow a procedure similar to that which currently exists for changing the designated hospice. Specifically, the patient (or representative) must file a signed statement with the hospice that identifies the new attending physician in enough detail so that it is clear which physician or NP was designated as the new attending physician. The statement must include the date the change is to be effective, the date that the statement is signed and the patient’s (or representative’s) signature, along with an acknowledgement that this change in the attending physician is the patient’s (or representative’s) choice. The effective date of the change in attending physician cannot be earlier than the date the statement is signed.

Please Note: The attending physician elected by the patient may deny or refuse to follow a patient while in hospice services. This denial or refusal is not a reflection of the patient, doctor relationship. It is a result of the attending physician and his or her team not being available to the hospice team 24/7/365. Having a physician available 24/7/365 is critical for the proper management of a hospice patient. Front Range Hospice will always do what we can to ensure your attending physician continues to follow your healthcare needs. In the event we are not successful, our team will follow up with the patient, inform them of the situation and work with the patient on selecting a physician of their choice.

If you would like more information about Front Range Hospice and how we work with your attending physician please call 303-957-3101 or 970-776-8080 or email us at info@frhospice.com

Watch out for our next blog: Hospice Care and Nursing Facility Relationships

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Do You Know What Matters To Me at the End of My Life?

Do You Know What Matters To Me at the End of My Life?

By Victor Montour

It’s not easy to talk about how you want the end of your life to be. But it’s one of the most important conversations you can have with your loved ones. Front Range Hospice has partnered with the Conversation Project to help you have The Conversation.

What is the Conversation Project, You ask? Let me tell you, The Conversation Project is not about filling out Advance Directives or other medical forms. It’s about talking to your loved ones about what you or they want for end-of-life care. Whether you’re getting ready to tell someone what you want, or you want to help someone else get ready to talk. We want to help you to be the expert on your wishes and those of your loved ones. Not the doctors or nurses. Not the end-of-life experts.  You.

Pam Ware CEO/Owner of Front Range Hospice has completed the program provided by The Conversation Project so she can present this wonderful program to people in the communities we serve and beyond. When you attend The Conversation Project presentation, Pam takes you on a journey of personal experience with the end of life process.

You don’t want to talk about dying, one thing’s for sure—you’re not alone. There are a million reasons to avoid having the conversation. But it’s vitally important. Pam and the Front Range Hospice team are here to help you and your loved ones have The Conversation.

Why talk about it now you ask?  Consider the following facts before you avoid The Conversation again. There’s a big gap between what people say they want and what actually happens.

  • 60% of people say that making sure their family is not burdened by tough decisions is “extremely important”
  • 56% have not communicated their end-of-life wishes

Source: Survey of Californians by the California HealthCare Foundation (2012)

  • 70% of people say they prefer to die at home
  • 70% die in a hospital, nursing home, or long-term care facility

Source: Centers for Disease Control (2005)

  • 80% of people say that if seriously ill, they would want to talk to their doctor about end-of-life care
  • 7% report having had an end-of-life conversation with their doctor

Source: Survey of Californians by the California HealthCare Foundation (2012)

  • 82% of people say it’s important to put their wishes in writing
  • 23% have actually done it

Source: Survey of Californians by the California HealthCare Foundation (2012)

Once you attend one of the Conversation Project presentations provided by Pam, you’ll see that this isn’t really about dying—it’s about figuring out how you want to live, till the very end. The Conversation Project will help you think about the things that are most important to you. It will help you think about what you value most. It will help you think about what you can or cannot imagine living without.  “What matters to me at the end of my life is _____” the questions everyone should know the answer to.

Sharing your “What matters to me” statement with your loved ones could be a big help down the road. It could help them communicate to your doctor what abilities are most important to you—what’s worth pursuing treatment for and what isn’t.

When you think about the last phase of your life, what’s most important to you?
How would you like this phase to be?

  • Would you prefer to be actively involved in decisions about your care?
    Or would you rather have your doctors do what they think is best?
  • Are there circumstances that you would consider worse than death?
    (Long-term need of a breathing machine or feeding tube, not being able to recognize your loved ones)
  • Where do you want (or not want) to receive care?
    (Home, nursing facility, hospital)
  • What kinds of aggressive treatment would you want (or not want)?
    (Resuscitation if your heart stops, breathing machine, feeding tube)
  • When would it be okay to shift from a focus on curative care to a focus on comfort care alone?

The Conversation Project will help you think about these questions and the basics like, who do you, want to talk to? When is a good time to talk? Where would you feel comfortable talking? What do you want to be sure to say? Lastly and most important, how to start the conversation.

You may or may not already know what you want to talk about and that’s great. It’s important for you to remember that this conversation will bring up some strong emotions in some individuals. The following is a small list of suggestions to consider before, during and after you have The Conversation with your loved ones.

  • Be patient. Some people may need a little more time to think.
  • You don’t have to steer the conversation; just let it happen.
  • Don’t judge. A “good” death means different things to different people.
  • Nothing is set in stone. You and your loved ones can always change your minds as circumstances shift.
  • This is the first of many conversations—you don’t have to cover everyone or everything right now.

If you would like more information about Front Range Hospice and The Conversation Project please call 303-957-3101 or 970-776-8080 or email us at info@frhospice.com

Watch out for our next blog: Attending Physician – You Have a Choice

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FRONT RANGE HOSPICE: Recognized by the Studer Group as Health Care Organization of the Month

May 1, 2015

FRONT RANGE HOSPICE: Recognized by the Studer Group as Health Care Organization of the Month

The Studer Group is a Health Care consulting firm that has a large base in the United States and is also in Canada, Australia, and South East Asia. “Studer Group partners with healthcare organizations to build a sustainable culture that promotes accountability, fosters innovation, and consistently delivers a great patient experience and the best quality outcomes over time.” says BG Porter, the CEO of the Studer Group.

Front Range Hospice has been recognized by the Studer Group as the first hospice to receive HealthCare Organization of the Month for May, 2015. This award is given to a Health Care Organization that achieves excellence in employee retention and patient and family experience of the care provided. This is the first time this prestigious award of excellence has been earned by a small hospice. “When the heart and the intention are given proven tools, amazing things can happen” says Pam Ware, MSW, LCSW, Founder and CEO of Front Range Hospice.

Ms. Ware practiced oncology social work for twenty five years, providing support and education to cancer patients, especially those that were considered terminal and had chosen very aggressive treatment. After twenty five years she wanted to do more to improve end of life care and create a workplace that supported professionals in the healthcare field to do the work that makes their heart sing. She worked as the Administrator for a hospice in Metro Denver for about three years before investing her life savings into Front Range Hospice, a small hospice that serves North East Colorado.

In 2006, during the startup phase of Front Range Hospice, Ms. Ware made the decision that the agency needed to be aligned with the Joint Commission (JC). JC is considered the gold standard for health care organizations. Front Range Hospice was the first privately owned hospice in Colorado to achieve JC accreditation.

In December of 2011, Ms. Ware,  read Hardwiring Excellence by Quint Studer. She immediately called the Studer Group office and began to explore how she could align Front Range Hospice with the Studer Group. Front Range Hospice began its formal consulting relationship with Studer Group in Feb of 2012.

At the end of 2014, after partnering with The Studer Group for three years, Front Range Hospice’s employee retention rate went from 33% to 98% and the Family Experience of the Care went from below the National average in all six domains to above the National Average in all six domains measured. These domains are: Coordination of Care, Attending to Family Needs, Informing and Communicating about Patients, Providing information about Symptoms, the Overall Quality of Care and finally, the Response to Evening and Weekend needs. These results are achievable once the leadership of an organization sets realistic goals, is transparent in its operations, and hardwires its processes.

“The leadership team and staff at Front Range Hospice have made a tremendous commitment of quality and service to the community. With this commitment came a promise to be relentless in doing whatever it takes to ensure that they not only meet the expectations of those that come to them for service, but exceed those expectations.  I have found that these leaders are never ok with average: they are committed to their belief that their community deserves only the best,” says Donny Cook, Studer Group Rural Regional Account Leader.

The mission statement of Front Range Hospice is to provide Legendary End of Life Care. The mission of the Studer Group is to make healthcare a better place for employees to work, physicians to practice medicine and patients to receive care.  The Studer Group has trained the leadership team on how to create a culture of excellence even in an environment of constant change. “Although the HealthCare Organization of the Month award was given to Front Range Hospice to acknowledge their commitment to excellence it would not be possible if we did not have the trust of the patients and families who chose us to provide their end of life care” says Ms. Ware.

“Health care is constantly changing which means processes need to be constantly analyzed for their appropriateness in our changing environment. The tools we have in place today may not work in the future but with our clearly defined goals, we are capable of changing our processes rapidly” say Lisa Foster, RN, Director of Nursing for Front Range Hospice.

The team at Front Range Hospice and most hospice professionals feel called to do this work. The care providers at Front Range Hospice understand that there are no do overs in end of life care. With the help of the Studer Group, Front Range Hospice has developed into an organization where that passion is ignited and shared with our patients, families and community partners.

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Who Cares For the Doctor?

Who Cares For the Doctor?
By Victor Montour

The hospice concept places the patient and family at the center of care, surrounded by the hospice team.  This last month I was forced to look at this concept and found the referring doctor is a loose member of the hospice team we may forget about. The doctor who is involved in the care of their patient may not be involved in the hospice meetings but they are a part of the team.  The potential problem with this model is that after taking care of a patient for a long time, the doctor is often close to the patient and more or less, emotionally attached.  Referring a patient to hospice may result in a significant loss to the doctor. Who cares for the doctor now?

Most hospices usually do not maintain a close conversation or bond with the primary doctor. The hospice sends the required paperwork and calls with the occasional emergency, but often the next significant contact after the original referral, is to notify the physician of the patient’s death.  For those doctors who are not comfortable with end-of-life care, this professional and functional distance may be acceptable.  However, for many doctors who fight fatal diseases month after month or even year after year in each patient, the loss of connection is draining.

This last month Front Range Hospice again raised the bar on quality. We do and will say, “Hey doc, how are you doing? This must be hard on you.”  The doctor’s loss and pain should be acknowledged. Generally, that is OK.  It is not the job of the health care system to heal a physicians wound, but the right thing to do is to reach out to that doctor, offer a caring gesture of concern and willingness to support them during a time of loss. I can’t help but wonder if one of the causes of the late hospice referral is the abrupt severing of invested patient-physician relationships.  Front Range Hospice cannot and will not ignore the pain which comes from loosing patient after patient and having no one say, “Are you alright?” This is just another way Front Range Hospice stands out from its competitors.

Front Range Hospice is committed to supporting all care providers closely involved in the care of our patients. After all the doctor explains hospice to the patient and family, they make a point of saying that they will still take care of them, that they would be closely involved and that the hospice is not “taking over.”

We as hospice providers must remember that doctors are human and, not rarely, they fall in love with the patients and families held gently in their hands.  Perhaps, sometimes, it might help if someone would hold the doctor as gently and say, hey doc, we care about you.

If you would like more information about Front Range Hospice and how we support and care for all of our healthcare providers and partners please call 303-957-3101 or 970-776-8080 or email us at info@frhospice.com

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