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Part 1: Referral Development and Initial and Comprehensive Assessment
Will present the Case Study and clarify the intended process for the 4 week Class. This will also include references to CoPs and licensing rules.
The speaker identifies the pertinent initial referral information obtained PRIOR to deciding to admit the patient. Explains why that information is crucial.
We will discuss how the dirty work of obtaining patient history, physician discussions and recommendations, patient/family discussions, pre-hospice or consult visit and how the ultimate decision to admit this patient to hospice is determined.
Included in this discussion is that information is given to the patient/family about hospice services, what is and is not covered, discussions about medications, family dynamics, hospice role, hospitalizations, respite services, or whatever else the family identifies—dispel myths, misconceptions, and lay out the in-depth regulatory compliance rationale for services to be provided by hospice. This is likely the initial visit with the patient/family. This meeting does not automatically become the time the patient/family ELECT the benefit. This is the time for the hospice representative to explain the term “electing” the hospice benefit; it is not just “signing up”—there are specific consequences to electing the benefit and this must be disclosed fully and completely to the patient/family. Sometimes, it is best to allow the family to breathe about this decision.
Speaker will identify what steps were taken and how the pre-hospice or consult visit was conducted; identify if the patient elected hospice or chose to wait.
Part 2: Developing The Comprehensive Assessment
We will begin discussion and rationale for the content of the comprehensive assessment and how it builds and ultimately creates the plan of care. Step by step including how the IDG works together to craft the Plan of Care. Includes immediate needs such as pain and other symptom control, DME needs, pharmacy decisions, and then how the IDG formulates that overall Plan of Care. Discuss how to think about the goals for this particular scenario involving the patient’s goals, the family’s goals, and the objectives for care that are identified by the IDG and communicated to the patient and family. Include how the aides are involved and directed including writing the aide care plan, supervision of the aide (and include for information how to include the annual supervision of the aide in hospice).
Discuss the Social Worker’s and Chaplain’s responsibilities, including Bereavement, in caring for this patient and how these disciplines into the Comprehensive Assessment formulation. Discuss how social work phone calls are documented and reported in hospice. Discuss how to determine which DME is reasonable and necessary and how t document those decisions; discuss safety issues with DME and that DME companies must be accredited and the documentation that the hospice must have on hand for a survey. We will touch on DME contracts and what should be included.
Pharmacy issues will be addressed including some contract language, coverage of medications in relation to this scenario and the possibility of discontinuing medications and how to deal with that, what to look for when contracting with a pharmacy such as pharmacist on call, benchmarking, consultations, etc. It’s not always about the pricing.
Part 3: Making The Plan Of Care A Living Document
The speaker will discuss any other changes in the patient’s situation and indicate how the IDG updates the Plan of Care based from the skilled nursing documentation (provide any specific patient details which support the need to make significant changes in the patient’s Plan of Care). We will be discussing the critical thinking required to ensure appropriate hospice care decisions. We will include documentation or discussions with the medical director and/or attending physician that played into the IDG’s decision making to amend the Plan of Care. We will discuss how the patient and family are kept up to date.
Part 4: A Review Of Documentation
In this session, the skilled nursing and other disciplines including the aide visits will be scrutinized for the last few visits prior to death. We will discuss how documentation should reflect the patient’s and family’s changing condition and how this documentation should accurately and collectively support the team’s assessments.
THE DEATH CALL
Provide an updated clinical assessment and significant change in condition resulting in the death call. Describe what steps the nurse must take and how these steps are to be documented. Include any other discipline that might assist in the death call. Then, depending on if the patient was deceased upon the nurse’s arrival, explain how that documentation must reflect exactly what occurs and the billing implications behind it. Once the patient is declared deceased, explain the after-care, dealing with the body; helping the family; calling the funeral home or a JP (whatever the protocol in your county) and all of the documentation that is required.
Generally, at the next team meeting, they must reflect on how ready the patient and family were for accepting the inevitable death. What was reflected in the IDG updates to the POC? What was done all along the patient’s hospice stay to meet the patient/family goals, ensure symptom control and pain management, meet their social and spiritual needs? Bereavement takes over, but what are the next steps and how is this documented?
There will be a brief post-death update on the family after 6 months. Depending on the family’s response to bereavement, discuss how the team should address any need to intervene. Describe where this documentation would be kept.
A final discussion will include the speaker’s identification of the overall patient’s hospice stay, its success (or details of what was not successful), what could have been done to improve the hospice stay (if anything), and how the family fared after the 12-13 months of bereavement care.