General Purpose of the Department:

As we have learned, the hospice idea is not new.  Literally  meaning "given to hospitality,"  hospices provided comfort, kindness, and nourishment to people in need hundreds of years ago.  Today, hospices offer comfort to people as they near the end of life's journey.  

Hospice is a special way of caring for people with terminal illnesses and their families.   It is  a multidisciplinary health care program that is responsible for palliative and supportive care with consideration of the patient's and families wishes.  Hospice focuses on care, not cure.  

Hospice care is important because it provides many benefits that aren't possible in a traditional acute or long-term health care setting.  Within hospice, the family of the patient is directly involved in making decisions and helping their loved one.  Hospice also gives the patient to have a great amount of control by deciding where they want to spend the rest of their lives.  It can also help make choices about advanced directives which we will discuss shortly.


Major Functions of the Department:

Hospice is a very unique department because it truly looks at the "big picture" and treats a spectrum of patient needs equally.  Special attention is given to:

Physical needs - this is the first and foremost function.  Within hospice you are dealing with a patient that has been given a diagnosis of having 6 months or less to live.  For many patients, relieving pain through medication is an important part of hospice care.  I have provided you with a list of ways that patients are made more comfortable.  A goal of hospice it to help patients use their physical abilities as fully as possible.

Social Needs - Sometimes little things make all the difference to people.  Although these patients may not be as active as before their illness, you can see on your handout a list of things that they probably still enjoy.  Hospice can help to make these things happen, as well as provide assistance with practical issues like putting finances in order.

Emotional Needs: Hospice can help patients cope with loneliness, isolation, and the fear of being abandoned.  This is outlined on your handout as to how the hospice staff accomplishes this.  Hospice also helps friends and families of the patient express their emotions through  group and bereavement counseling.

Spiritual Needs - the realization that a person's spirituality is of a daily concern to the patient has led hospice care to this area.  Hospice tries to organize the types of care outlined on your handout.  Members of the clergy can also help family and friends who are in need of spiritual support.

As you can now see, there are many areas of patient care that hospice has a direct focus on.  This now brings me to the subject of the people involved:  the staff.
Staffing of the Department:

As with all departments, the actual number of staff will vary by facility.  However, there are required members of the staff that must have certain qualifications.  For instance, there must be nurses to do in-home care.  These nurses can be either RN's or LPN's depending on the level of patient care involved.  In addition is a staff physician who consults with the patient's primary care physician  and helps to oversee the patient care plan.  In addition, there are is a staff psychiatrist and a psychologist who do individual and family counseling, volunteer visits, holiday programs, support groups, and learning about loss and grief.  Some hospices help with funeral arrangements.  Also part of the hospice team are the hospice coordinator or director, other consulting physicians and specialists, a member of the clergy, a social worker, a dietitian, a pharmacist, therapists who perform physical and occupational therapy.  Also there are home care aides and volunteers.  Hospice members offer care for patients on-call 24-hours a day.

Depending on the patient's needs at the time, hospice care is provided in a variety of settings including the patient's home, inpatient facilities including a nursing home, or a combination of venues.  

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Special Requirements:

Staff needs to be oriented in the special situations that arise in dealing with a patient in their own home.  Respect for the patient and their surroundings is of utmost importance.  Being empathetic to even the smallest of concerns is the mark of a well-trained care-giver.  There must be an emphasis on maintaining a quality of life that the patient as well as the family feel comfortable with.  

Since the patient is treated by such a wide variety of workers, there are weekly case management meetings which are mandated by Medicare, but often also influenced by hospital policy to ensure quality of care.    It is at this time that information is shared by all who have had contact with the patient and any concerns are addressed.  This helps for the staff to work out their feelings as well - because in hospice care where you may treat a patient for a year or more, bonds   begin to form.


Reports, Statistics, and Records:

I would like to spend a bit of time on this subject in consideration of the nature of our program.  As director of the hospice program, one duty that would fall on you is the compilation of statistics, the submitting of reports, and the overseeing of the legal medical record.

Since hospice keeps it's own legal medical record on their patients, their relationship with the medical record department is very limited.  If a hospice patient checks in to the hospital, there must be a release of information from hospice to the hospital in order to share information.

Upon death, however, the hospice record is integrated with any hospital records into one main file which is archived according to hospital policy on deceased charts.

Statistics compiled by this department include those reportable to the Montana Hospital Association such as number of referrals and number of Medicare patients.   Reportable to Medicare are unduplicated patient days, social security numbers, diagnosis, and other demographic information.  Hospital statistics may typically include patient days, cost of supplies and equipment broken down through the different disciplines, pharmacy costs, and number of visits with the patient.  Also implemented would be a quality assurance program which gathers input from the patient in the form of a pain questionnaire.  A questionnaire is  also given to the family after the patient dies to evaluate their satisfaction with the way  that hospice treated the patient as well as the family unit.  

In your folder, you will se on the right side an intake check list which is completed by the supervisor.  When all necessary forms are in the chart, hospice care officially begins.  

(Review info in chart)

Along with these forms, there will also be nursing notes, medication orders, doctors orders, among other forms that are typical for an inpatient record in an acute care setting.  

JCAHO Standards:

In reviewing Joint Commission's Accreditation manual for Health Care Organizations, I came across many standards that directly apply to hospice care.  You can see on your handout a sampling of a standard from different sections in the manual.

For the first section I am covering, Rights , Responsibilities, and Ethics (RI) under the treatment section is  RI.1.2 which reads:
[The organization has a functioning process in place to address and respect patient rights:  the process is supported by a framework that includes the following mechanisms:] Mechanisms for the individual and, when appropriate, the family to receive sufficient information on the individual's responsibilities in the care process

This can be implemented in hospice by informing, assessing, educating patient and their families in their responsibilities in the care process such as administering pain medications or treatments.

The next section I am covering is Assessment (PE).  The standard I am looking at is PE.1.2 which reads:

The scope and intensity of any further assessment is determined by the patient's diagnosis, condition, need and desire for  care and services, response to previous care, and the care or service setting.

Implementing this standard in hospice would be for hospice patients and families, the bereavement assessment begins at admission, and is updates as appropriate during the patient's time in the program, at the time of death, and during bereavement follow-up.

Next is Care, Treatment, and Services (TX).  Standard TX1.2.2 reads:

When applicable to the care provided, the physician or other authorized individual reviews and revises therapeutic and diagnostic orders as necessary.  

So, the provision of Hospice care is in accordance with therapeutic orders from the patient's attending physician and/or the hospice medical director and the hospice interdisciplinary team.  This might include hospice standing orders for symptom management (for example, control of nausea and vomiting, bowel management) and other palliative care measures such as oxygen, as needed.

The next section deals with Education (PF).  Standard PF.2 reads:

The patient and family receive education and training specific to the patient's assessed needs, abilities, and readiness, as appropriate to the care and service provided by the organization.  

As part of it's overall education plan, a hospice develops written teaching materials geared toward family members and caregivers on caring for a hospice patient in the home.  The teaching materials address such aspects as medication administration, caring for a bed bound patient, skin care, nutrition, signs and symptoms of impending death, and the preparation for and handling of a death in the home.  Hospice interdisciplinary team members also teach the family about such issues as communication and coping styles; the psychosocial and spiritual needs of dying people such as "needing permission to die," "saying good-bye" ; letting go of the patient; and managing grief and loss.

Though there are other important sections in the manual, because of time limitations, I am going to cover only one more section which is Surveillance, Prevention, and Control of Infection.  IC.1 reads:

Processes are in place to reduce risks for infections in patients and staff members.

This is implemented by determining that the surveillance of infections among patients and staff will include tuberculosis, hepatitis, and HIV, as well as new incidences of central venous catheter infections or wound infections.  Surveillance identifies a trend of staph infections among patients with pressure ulcers, and planning includes the identification of mechanisms both to prevent skin breakdown and prevent infections in acquired open wounds.

This section of the manual is the real meat of keeping in line with OSHA guidelines.  In hospice care, the control of bloodborne pathogen exposure is utmost and it is required that there be an exposure control plan that is to be read by employees and signed as having been read.  

Complying with OSHA guidelines is looked at very closely by the risk management committee who keeps a sharp eye on Home Health because so many potentially dangerous situations arise when entering a patient's home.  


Cost Containment Issues:

Within hospice, there is not a too big of a worry on cost of care.  Because of Medicare's Hospice Plan paying 100% of the patient's bill, the patient has less to worry about.  As in most other areas of the hospital, however, risk management and the potential for loss of dollars is the major concern.  As I mentioned, special care must be taken when entering a patient's home and additional things need to be looked at such as slippery walks, loose dogs, and traffic when getting to the patient's home.

As you can tell, hospice is a very complex, very necessary service which has many rewards.  I hope I have helped you to have a better understanding of this department and the services they provide.  In your packet you will find several brochures which you may want to look at in the future.

Are there any questions?