Nursing Home Social Services Reference/Flow of Care/Hospice

Residents living in a nursing home have the service of hospice available to them. They can choose any hospice they wish to work with. More typically, nursing homes establish relationships with a few, usually between 2-5 hospices, to provide residents more of a choice. Working closely with a few chosen hospices improves service delivery, enhances communication between the nursing home and hospice, and makes it easier for hospices to deliver care to more than one client. Ultimately though, the resident can choose any hospice they want, and the nursing home is obligated to comply. When nursing staff feel a hospice evaluation could be useful to a resident's care, they will bring it up to the resident and/or their decision maker, usually family, guardian, or friend. Nursing home staff are able to provide an overview of hospice services, but it is best left to the hospice to introduce their agency and explain their services. Once a hospice has been chosen to complete an evaluation, the hospice will send an intake nurse who will meet with and assess the resident and review their medical records. Medicare is generally the insurer for hospice and the criteria for hospice agency staffing and services are specified in Medicare regulations for eligible hospice services. Hospice can be paid for privately though this happens rarely. The criteria for getting onto hospice with Medicare is typically a doctors evaluation stating the resident has six months or less to live unless the resident has a diagnosis of cancer in which case the period of hospice care can be one year. Many think, why is hospice needed when they live in a nursing home with nurses on staff 24/7? Hospice has a completely different perspective on how to provide care. Hospice aims to ensure a resident is comfortable until death and all curative and/or preventative care is ceased. A nursing home aims to heal for a better life, while hospice aims to comfort for a better death. Hospices may discontinue a resident's medications, change out their durable medical equipment like a hospital bed, and visit the client on a weekly or daily basis in addition to all the services a nursing home provides. The hospice then becomes the primary on all decisions related to the resident's medical care and the nursing home follows the orders and plan of care from the hospice. When a resident is getting the care they need, often they can get better and "graduate" from hospice. They may be placed on palliative care where a nurse from the hospice or palliative agency visits them once a month to monitor them for any changes of condition that might make them eligible again for hospice. Both nursing home and hospice staff are expected to work together harmoniously with the goal of providing the most benefit to the resident. Key to this goal are ensuring good and complete communication, sharing of updates on resident status, and alerting the hospice when the resident has warning signs of imminent passing are very important. Nursing homes are busy, but they must ensure the hospice agency is kept updated. Social services are part of the coordination of hospice services. While nursing provides the medical records for the referral, social services will often send the referral or calls the hospice to discuss the resident prior to them coming out for an evaluation. Social services also ensures that hospice is involved when a resident is due for their care conference or any meetings related to their care. Admissions and marketing may also be involved due to their focus on establishing relationships with community agencies such as hospice. Every hospice must have a social worker and chaplain on staff to visit the resident at least once and once per month or more often based on the resident's needs and willingness. It is important for social services to communicate with the hospice social worker or chaplain. Welcome any and all feedback and input from outside sources. The goal of social services is to enhance residents' lives, which means being open to outsider input. Sharing your perspective and hearing the perspective of these professionals will help you be a team working to meet the the resident's needs. Hospice and nursing homes work together to care for residents who are nearing end of life (EOL). It is the special mission of hospice to prioritize the EOL needs of residents. This relationship between the hospice and the nursing home can be nurtured and enhanced by social services.