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

Posted in Uncategorized | Tagged , , , , , | Leave a comment

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

Posted in Uncategorized | Tagged , , , , , | Leave a comment

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

Posted in Uncategorized | Tagged , , , , | Leave a comment

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.

Posted in Uncategorized | Tagged , , , , , | Leave a comment

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

Posted in Uncategorized | Tagged , , , , , , | Leave a comment

Volunteering at the End of Life

Volunteering at the End of Life
By Victor Montour

In honor of National Volunteer Week Front Range Hospice would like to take a moment to say Thank You to our wonderful volunteers. Your selfless acts of kindness and unwavering strength are appreciated by all of us at Front Range Hospice.

Hospice care is an end-of-life-care model that focuses on enhancing quality of life when time is short. It involves an inter-disciplinary team – including doctors, nurses, social workers, chaplin, and social worker, — working together addressing the medical, physical, social, emotional and spiritual needs of the patient, as well as providing bereavement support to the family. In keeping with hospices deeply humane and community-service the team also includes volunteers.

“Front Range Hospice Volunteers are an integral and valued part of the team,” says Jen Jackson, Volunteer Coordinator for Front Range Hospice. “They provide that extra level of care and comfort that neighbors used to provide for free, without thinking about it.”

Volunteers provide nonprofessional services but are required to undergo intensive training, including interviews and background checks. Our organization asks volunteers to commit to at least one year of service, visiting with one patient one hour per week in the home or where the patient calls home. This could be in an assisted living, skilled nursing facility or small board and care home. Volunteer services can be as varied as those of any personal relationship and can include but not limited to:

  • Support for patients
  • Respite and support for family members
  • Vigil services (when death is imminent)
  • Bereavement support

Volunteers might sing show tunes with patients, talk about the Yankees, share in watching a favorite soap opera, help compile “final projects” or life reviews and bring in pets for comfort (only at the patient’s request, of course). Fundamentally, volunteers provide the most elemental of life’s needs, a hand to hold or an ear to listen. It’s really about showing up and being present that day, that minute, that hour — meeting the patient where they are.

Sometimes our volunteers are asked if it is difficult to be a hospice volunteer, to get to know someone only to have them pass away. The short answer is no. It is rewarding, transformative and life-affirming. The longer answer involves death as part of the continuum of life, understanding expectations, maintaining personal boundaries and undergoing adequate training and education.

The surprising secret of hospice care is that it’s not depleting, what Front Range Hospice volunteers do is useful, and someone needs them. These patients would be going through what they’re going through whether or not our volunteers are there. Front Range Hospice volunteers, as with all those involved in hospice, understand that death is a part of life. They accept the process.

Some hospice volunteers are inspired to become a volunteer because of the immense support they felt from hospice when their loved one died.  Some hospice volunteers call the work a gratifying, loving experience. There’s no pretense, no façade — just honesty. The bond volunteers have with a patient usually escalates because of the limitation of time, so they have to seize the moment.

Whether you’ve had a family connection to hospice care and want to give back, or are interested in learning more about how to support and comfort those in their final days, I encourage you to explore this truly rewarding volunteer opportunity.

Thank you again to all of those who volunteer. The services you provide are priceless.

If you would like more information about Front Range Hospice and how you can become one of our volunteers please call 303-957-3101 or 970-776-8080 or email us at info@frhospice.com

Watch out for our next blog: Who Cares for the Doctor?

Posted in Uncategorized | Tagged , , , , , | Leave a comment

Morphine and Pain

Morphine and Pain
By Victor Montour

Hospice advocates good pain control for terminally ill patients, even to the point of using narcotic drugs (we call them opiates) such as morphine as they are needed. With all the concern about drug abuse, patients, families and friends sometimes question the use of narcotics. Are we pushing “dope”? Or are we practicing good medicine? I want to explore some of the myths about the use of narcotics for pain control with you

Myth #1: Morphine is offered to patients only when death is imminent.

It is not the stage or phase of a terminal illness, but the degree of pain a patient is having that dictates which medicine to use. We start low with the mildest medicine and if it works, we stop there. If it doesn’t we move slowly onto the next best level of pain control. We move to morphine when it’s appropriate. Some people never need morphine, while others will require it for quite a while. Patients can live for a long time while appropriately taking morphine for pain control. Low and slow is the best way to progress any pain medication.

Myth #2: People who take morphine will become addicted.

Let’s talk a bit about drug addiction. Drug addicts are people who are driven by their need for narcotics; they may commit crimes or harm others to get their needs met. Hospice patients usually don’t have drug-seeking behavior. When a patient’s pain is in good control, they don’t desire more pain medications. Sometimes we can even decrease the dosage. If patients take morphine for a while, their body may become used to it and it should not be suddenly stopped. Stopping the medication abruptly may cause side effects to occur. Side effects of a medication should not be confused with addiction or withdrawal.

Myth #3: People who take morphine will become so sedated (sleepy) that they can’t function.

When patients start to take medications like morphine or other opiates, they often feel drowsy, this drowsiness usually diminishes within a few days and their bodies usually will very quickly build up a resistance to the sedating effects. Most patients whose pain is well controlled on morphine are not bothered by unusual sleepiness. Some people, however, notice a difference in their alertness and might choose somewhat less than perfect pain control as a tradeoff.

Myth #4: People who take morphine die sooner.

Because morphine is used regularly in hospice, patients quickly adjust to any effect that morphine may have. We prescribe a small initial dose, gradually increasing it if needed. In fact; morphine is a drug of choice for breathing distress, commonly referred to as air hunger, in people with end-stage heart and lung disease. It will relax the heart or lungs making the patient more comfortable. This is especially true in patients with lung disease. In the end stage of lung disease the patient is not able to take a deep breath so the inhalers that they may have been using for years are no longer effective.

Myth #5: I’m allergic to morphine: once I had a shot of morphine after an operation and I felt very strange.

Of course you can be allergic to morphine just like any other medicine. But feeling strange is not a sign of morphine allergy usually. Some people may have unpleasant mental sensations temporarily when they start to take morphine. But that is not an allergy; and it might never recur. There are other opiates available for those people who are truly allergic to morphine. To learn more about allergic reactions see our blog post “Speak UP”.

Myth #6: Morphine must be given by injection.

Hospice is a leader in demonstrating the effectiveness of morphine and other opiates taken orally. People who required injections of morphine in the hospital (the most common way of giving morphine there) will probably be able to be well controlled on oral morphine at home. There are also long-acting preparations of morphine which can be given every twelve hours, or opiate skin patches which can be applied every 72 hours, to simplify the routine of pain control.

Myth #7: People should wait until their pain is bad to take morphine so it will be effective when it’s really needed.

There is no upper dose limit to the use of morphine or other opiates. If pain increases we can increase the dose; this is true of very few other medications. Using it when it’s needed early in the course of a terminal illness does not mean that it won’t continue to work later in the disease process.

Morphine, one of the oldest drugs in existence, has found a well-deserved place in the field of hospice whose mission is the relief of pain and other symptoms. We recommend opiates for pain control only if they are needed.

If you would like more information about Front Range Hospice and the use of Morphine, call 303-957-3101 or 970-776-8080 or email us at info@frhospice.com

Posted in Uncategorized | Tagged , , , , , | Leave a comment