How To Choose a Hospice: Why Recommendations Matter

(This post is part of a series of posts. To read from the begining of the series go here.)

There is little better than the recommendation from someone who has experience with a specific hospice. If you have friends that have used hospice in the past, you should talk to them. Be warned though that hospice is overwhelmingly popular with families who have used it, so one glowing recommendation doesn't mean you have found the best hospice. Again, most hospices are good at caring for the average patient, so if your friend's loved one was an average patient, you should expect a positive review. Ask your friend the questions from the other posts and see what you learn.

If your loved one lives in a nursing home, I'm going to assume that you have followed the instructions from part 2 that says that you should under no circumstances use a hospice that is owned by the nursing home or owned by the same person who owns the nursing home the patient lives in.

Assuming that is true, then here is some advice specifically for people looking for a hospice to come into a nursing home:

1. Ask the nursing home staff who they recommend. Usually they will have one that they use more than others or one that they think is best. The downside to this is that you have to make sure that the staff member you are talking to doesn't moonlight for the hospice they are recommending. It is common practice for a hospice to hire a nurse from the nursing home to do some part time work. Obviously, someone on the payroll of a hospice isn't an objective observer of which hospices are good and which are not.

2. Ask the nursing home staff if they can tell you the name of the best nurse from the hospice. Once you have that name, you can ask specifically to have that nurse Case Manage your loved one. This will help you avoid getting the rookie or the slacker. If you tell the hospice up front that it is important to you that you have a specific member of the staff, they will grant the request if it is at all possible. Remember, they want your business.

Notice in number one that I said the staff will either have one they like or one they think is best. Those two things don't always go hand in hand. Nursing homes often judge hospices by how much of their work they can push off on the hospice employees. Hospices that hold their ground and make the nursing home do their job are not always popular with the nursing home staff, but they are often good.

Ask more than one staff member at the nursing home and ask people on different shifts. The night nurse will know if the hospice on-call nurse comes quickly, while the morning nurse will know if the hospice Aide shows up on time and does the job well. Ask around and see what you find out. It may not be the best or most objective advice you ever get, but you'll learn a thing or two about your options.

How To Choose a Hospice: Why Staffing Matters

(This post is part of a series of posts. To read from the begining of the series go here.)

In "Why Size Matters", I talked about how many patients each nurse has. This time I want to talk about how much attention you should expect and who you should expect to get it from.

First, frequency of visits. Your nurse should visit at least twice a week. Any nurse that thinks they can keep up on a hospice patient's condition by visiting once a week is delusional. Find a hospice that promises a minimum of two nursing visits a week. It shouldn't be too hard.

Second, find out who makes the visits. The question you should ask is if the same nurse will visit every time. There are two different theories on how to use nurses. As with everything in hospice one is best for the patient and one is best for the pocketbook.

The theory you want your hospice to have is the theory that believes that having the same nurse seeing you every time generates better care. There are things that only an RN is allowed to do, and most of those things are only done once every two weeks. A good hospice has the RN make every nursing visit. That keeps them as up to date as possible. A not-so-good hospice has the RN make one visit a week and an LPN make the other. While this is better than those that offer only one visit a week, it is still not good enough. The biggest thing a nurse needs to know about a patient is what is normal. Some have high blood pressure, some low, some have a 98.6 temperature every day, some are a little lower, some are short of breath at all times, some are not. For a nurse to know when something is wrong, they have to know what it looks like when it is right. The only way to know these things is for the same nurse to see the patient every time. An RN make about $5 an hour more than a LPN so there is great pressure from the bean counters (especially in large corporate hospices) to use LPNs as much as possible. In those situations Case Managers may take care of 20-30 patients instead of the 12-15 I suggested earlier. I have nothing at all against LPNs, but for the sake of consistency, you should choose a hospice that doesn't use many LPNs. You want the same nurse to come every time. The only way that will happen is if RNs make all the visits. The routine use of LPNs is an indication that the hospice is taking care of the bottom line at the expense of the patient.

There are two more parts to this series. Next, find out why staff recomendations matter.

How To Choose a Hospice: Why Size Matters

(This post is part of a series of posts. To read from the begining of the series go here.)

No matter what they tell you, size does matter. To be honest, I can't decide how much it matters. That means that while this post is good advice, it is not as important as many of the other suggestions you'll receive in this series.

You don't want a hospice that is too big. You don't want a hospice that is too small. You want a hospice that is just right.

What is too big? I'd say anything over 90 patients in any given office. Make sure you find out how many the office closest to you has, because there are companies that have one huge office and many other offices that are a better size. You should only care about the office that you will be working with. As a hospice grows larger there is no way to avoid it becoming a more impersonal operation. The more patients one person oversees the more they become numbers and not real people. If the person who is making big decisions about your care doesn't know you or much about you, then you are not going to get anything better than routine care. Hospice patients often want or need something special or out of the ordinary; the larger the patient load the less likely that is going to happen.

What is too small? Less than 10 for sure, and probably less than 20. To find out if a hospice is too small ask how many full time Case Managers they have. A case manager is the head nurse for a patient. She is usually a RN, and is basically the person in charge of the patient. Most full-time Case Managers have 10-14 patients. If a company only has one Case Manager, they are too small. That Case Manager may be (and probably is) great, but you must ask what is going to happen when the Case Manager goes on vacation or has the flu. If the only nurse is sick, then the patients are not going to get good care; there is no way around that. Small hospices do awesome things for patients because they can focus intensely on one patient, but when the wheels fall off the bus, a small hospice can get in real trouble quickly.

What is just right? I don't know. There are a lot of factors that go into that question. I guess I'll say that 40-50 patients with five full-time Case Managers would be just right. That is not the size of my company, and few are going to be that size.

As I said at the start, I'm not sure how important size is in the grand scheme of things. I have no doubt that large hospices can give great care. It just takes a lot more effort on their part to keep everything personal. I also know that small hospices can be the best around, but they run the risk of one good stomach virus making them useless.

In the end, the real question probably is how many patients does each case manager have? I think 10 is a great number, but know that profits come when you get to 12 or so. Ask the hospice you are interviewing how many patients they have and then ask them how many full time Case Managers they have. Doing the math may tell you if they are overstaffed or understaffed. Overstaffed is bad for business but good for patients, so unless you are thinking about buying stock in the company choose one that is overstaffed.

How To Choose a Hospice: Why Pharmacies Matter

(This post is part of a series of posts. To read from the begining of the series go here.)

My thoughts on this subject have changed quite a bit since I first wrote this series in March of 2005. Then I was not a fan of hospices that use the large "mail order" hospice pharmacies, now I believe that those pharmacies may be the best option for some hospices.

Your hospice is in charge of providing all medications that are needed to control the symptoms associated with your hospice diagnosis. With that charge comes a lot of responsibility. Your goal is to have your pain controlled. The hospices goal is to control your pain in a cost effective manner. I used to think that a hospice that was willing to hire an out of state pharmacy was a sign that the hospice was more focused on the cost control side than the pain control side. While that instinct may not be 100% wrong, I am sure it is also not 100% right. What I have learned in the past few years is that there is one thing that is much more important than where your hospice purchases the drugs.

The important thing is how good the pharmacist is. The national mail order hospice pharmacies pride themselves on having pharmacists who specialize in hospice type drugs. They spend time and money studying the types of problems hospices face and the drugs that can best solve the problems. It is this type of drug knowledge that you want from the hospice you choose. Hospices use medications in a way that few understand. We use pain medications at levels that make many doctors uneasy. Hospice also uses many drugs for "off label" purposes. If your doctor (like many we work with) is not comfortable with using high level pain meds and doesn't know the "off label" uses of drugs, then you have one strike against you. If your hospice's pharmacist agrees with the doctor, then you have strike two and three.

No, this does not mean that you should choose a hospice just because it uses a mail order pharmacy. (I'm still not convinced that they are a great option for hospices.) What it does mean is that a great hospice is going to have a real relationship with its pharmacist. You are looking for a pharmacy/hospice relationship that entails much more than just filling prescriptions. No matter how good a hospice's nursing staff may be, there are times when they are going to need some serious research help. Being able to call your pharmacist, whether he is around the corner or in another state, and get well educated answers to serious questions is a key to good hospice care. Not every patient is going to need that kind of research or knowledge, but some patients require all the brainpower a hospice can find. Having real access to a pharmacist with some serious brainpower is one thing that really allows a hospice to care for its patients.

The other pharmacy consideration goes back to location. Even hospices that have mail order pharmacies must have a local pharmacy to do emergency quick fills. Find out which pharmacy that is. The further that pharmacy is from your house the longer you will have to wait for your emergency pain medications. Some hospices provide their patients with "emergency packs" to help solve this problem. This pack has one or two doses of the most commonly used emergency drugs, so that you have these drugs in your home just in case. This is a great idea, but there is always the chance that you will need an emergency drug that isn't in the pack. There is little substitute for a good 24/7 relationship between a hospice and its local pharmacy.

There are four more parts to this series. Next, find out why size matters

Hospice Conditions of Participation Workshop

This is not the first time where my membership in NHPCO has made it hard to know what I should or should not say on this blog. In theory, everything that I know to date about the new Medicare Hospice Conditions of Participation is from publically accessible information. In reality, there is no way that I would know everything that I know without the help of the National Hospice and Palliative Care Association. NHPCO has done a great job of getting insight and information out to its membership about the new COP's. They are in the middle of a two day workshop in Baltimore that is being webcast at no charge to NHPCO members. While the subject matter is dry, it is somewhat amazing to get to hear the people from CMS who actually drafted these rules talk about them. There are two women from CMS presenting, and they clearly know this subject well. In the introduction I believe they said one of them had been working on this project for ten years. Having the opportunity to hear those people tell us what they intended when they wrote these regulations has really helped me understand the intent behind the new regs.

With all of that said, I have chosen not to discuss specific regulations on this blog for a few weeks. It is my understanding that there are representatives from each state in the union attending this conference that is being webcast who were invited to learn this material and then teach it to their states. With that in mind, I don't want anyone to confuse this blog for a place to go to learn the regulations. Even if I started a discussion about some of the specific regulations, there is no way we could cover everything. When you see your state association or some other group offering the seminar that they are preparing for in Baltimore, you need to go. In fact, a bunch of people from your hospice need to go! There is a lot of information here, and the changes are not going to be easy. We, as a hospice industry have our work cut out, and you need to get your organization in the game if it isn't already.

Between these new regulations, the new billing requirements, the proposed hospice rate cuts, and the possibility of major changes in our payment system on the horizon, I really encourage those of you who are still trying to do hospice in a bubble to come on out and join the rest of the movement. NHPCO is working very hard to keep the industry safe, and they could really use your dues. You could also use their help! I promise you, you are going to be needing help over the next 6-9 months!

No, I do not work for NHPCO. Actually, if you review this blog's history, you'll probably find that I have not always been a fan of NHPCO, but we are well past the time where hospices can try to go it alone. We need to speak with one voice, and NHPCO has worked very hard to be that voice for all of us.

How To Choose a Hospice: Why Location Matters (updated)

(This post is part of a series of posts. To read from the begining of the series go here.)

For part three of this series I want to deal with the most important question - location, location, location.

I want to say from the top that I am not talking about where the office is located. Many hospices operate out of some really dumpy buildings in really bad locations. Hospice is one of the few businesses where the client almost never visits the office, so many hospices save some money by operating out of spaces that should be condemned. Many hospices operate out of houses instead of office buildings. All of this is to say that you should pay zero attention to what the office looks like or where it is.

Before I explain myself please know that of all the words I spill and all the advice I give in this series on how to choose a hospice this post is the one that should always be a deal breaker. If you talk to a hospice that answers every other question perfectly but fails this test, then you should not use it. I am against huge New York Stock Exchange company operated hospices, but if they are the only ones around that pass this test, then they are the company you should use. The issues I have discussed in the earlier posts hold theoretical potholes on the road to great hospice care. The location issue is not a theoretical one.

You need to know where the on-call nurse lives. No, you don't need to know the address of the nurse's house, but you need to know how far it is from the on-call nurse's house to the patient's residence. When you ask where the on-call nurse lives they are going to say that they have many different on-call nurses. While that is true, it does not answer your question, so ask it again. Keep asking the question until you know the answer.

Here's why this is important. The odds are very high that the patient you are shopping hospices for is going to wake up in pain, have seizures, fall out of bed, halocunate, or stop breathing while on hospice service. If this happens at 2am, then the amount of time between when the problem starts and when you can start finding a solution depends on how long it will take for the on-call nurse to get from their bed to the patients bed. It is that simple.

Remember from post number two in this series, our example hospice can cover anyone within 50 miles of their office, and with branch offices they could cover 99 miles from the home office. The hospices that trouble me most are ones who use one on-call nurse to cover multiple branches. Let's do the math. If the patient lives 40 miles north of the northern branch office and has a crisis (almost all hospice patients have a crisis) and the on-call nurse is visiting a patient that lives 40 miles south of the home office, then she will have to drive 40 miles north to get to the home office, 49 miles north to get to the branch office, and 40 miles further north to get to the patient. Your loved one is having a medical crisis and the nurse will have to drive 129 miles before anything can be done. That is 100% unacceptable! First rule of thumb, make sure there is always someone from the office closest to you that is on call. Second rule of thumb, make sure they are not covering call for other offices. The on-call nurse being your next door neighbor will not help you if she is with another patient 90 miles from home at your time of need.

The third rule of thumb is, if you live in the same town as the hospice office, make sure that their on-call staff lives in town also. Choosing the local hospice doesn't do much good if they hire on-call nurses that are not local. If the main on-call nurse lives 30 minutes from town, then you'll have to wait at least that long before help arrives. There may not be a hospice in your area that can promise that the on-call nurse will live close to you, but if there is, then that is almost always going to be the hospice you should use.

To summarize: Where the on-call nurse lives is probably the biggest thing you need to know before making your hospice decision. I'd rather use an unethical/money grubbing hospice that can promise quick response time than a great one that will make you wait an hour before they can get you. On a personal note, I believe my company and my staff are as good as any hospice could be, but I have told many possible patients that they should call another hospice because of this exact reason. If you are choosing between a 15 minute response time and a 45 minute response time, it should be a no-brain decision.

There are five more parts to this series. Next find out why pharmacies matter.