If you are a new hospice nurse, one of the tasks you dread is admitting a patient, especially if you have scheduled visits on the same day as the admission.
I want to share with you some tips that, when applied, may help lower your stress level and help you remain on time even in cases where you have three to four visits, including recertification, to do the same day.
Try to have whatever paperwork your agency uses for the admission completed. In the order, you will go through it with the family and patient.
Look at where all your patients live, including the admission if you have visits, plus the admission. Look up what you can on admission to prepare for SBAR medication and treatment recommendations, equipment needs, etc.
Call the patient and family before the admission to prepare them for the flow of events and to have handy what you will need to complete the admission. My calls go something like the following: “Hello. I am Peter, a registered nurse coming over to admit _______. I am seeing various patients today, and I believe I’ll be at your place (confirm the address/location) by such and such time (pause for a few seconds to see if they will interject anything about the time). There’s physical and electronic paperwork to go through and sign, so we will need a smoke-free area to sit, write, and sign papers. This process typically takes 15 to 30 minutes. I’ll need to see your loved one’s insurance card(s), discharge paperwork (if the patient just came from a hospital setting), living will for healthcare if you have it handy (it’s not necessary), durable power of attorney paperwork (it’s not necessary). Pause. I’ll also need to see the original bottles of all medications. Pause. Once we get through the physical and electronic paperwork, I will do a head-to-toe assessment of your loved one, which takes about 15 minutes. After that, I will review your medications on the phone with our medical director (or provider) to see what they recommend keeping, changing, or discontinuing and which medications will be provided/covered by hospice. Pause. Do you have any questions?”
When you arrive at the admission, if the patient is not signing their consents, ask to spend just a moment with them to lay eyes, hear them, and introduce themselves. You are going to have admissions where the patient is in the process of dying when you get there or shortly after that. The compassionate thing to do is put the patient first and then deal with the paperwork.
Then, flow through the paperwork following the Keep It Simple and Smile (K.I.S.S.) approach, where you highlight the key points and pay attention to the person who will be signing’s body language for how fast and slow to go. Hospice is an elective service; we must remember they will get copies of everything. You are not a lawyer, let alone their lawyer; don’t complicate it by reading line-by-line or going into great detail. Stick with the major topics.
After the consent and financial paperwork (including electronic) are signed, do your head-to-toe assessment. SPOILER Alert: one of the best ways to approach the full-code vs. DNR paperwork (POLST in Pennsylvania) is to premise the conversation with something like the following: “When you start to die from your terminal illness, do you, your family, and our team to keep you comfortable and allow you to pass naturally?” Sometimes, I will get those who ask for an alternative. Then I go into the stats that CPR does not mean resuscitation (it’s not guaranteed, and in the home setting, approximately one out of one hundred make it to the ER). That family will have to do the CRP until EMS arrives… most of the time, the patient and family go the DNR route.
For the head-to-toe assessment, remember the admitting diagnosis, related dx to the terminal prognosis, and the comorbid conditions in terms of areas to focus on. Also, it’s always a good idea to get the height, weight, MAC (a measurement in centimeters two finger-widths above the elbow; thigh circumference can also be used), FAST scale (for any dementia, not just Alzheimer’s), Palliative Performance Scale (PPS), O2 sats (noting the circumstances such as at rest, on XL o2 via what means), as well as ADL’s/IADL, ‘s the patient needs help with daily, estimates on food/fluid intake per day, estimates on awake vs. sleeping/napping hours per day, and continence of bowel and bladder. As you assess, please remember that this information will provide the foundation for tracking declines to prove continued eligibility for hospice services.
Now, it is time to review the medications. For this, I recommend the two-pass method. As you grow in experience as a hospice nurse, you are going to get good with medications as well as what is typically changed (i.e., our hospice changes pantoprazole to omeprazole 100% of the time), what is typically discontinued, what will and will not be covered. Before I call the provider, I like to do the first pass to see what they know about the medications and get their thoughts on the potential changes. That allows me to know hot spots that need to be addressed before the call versus being surprised during the call. I then call the provider, go over the diagnosis first (to get a list of related vs. unrelated, and this plays a significant role in what medications will be covered by hospice), and then (typically with the provider on speakerphone where they are asked if it is ok to be on speakerphone prior) go over the mediations. At the end (if the patient or family didn’t interject during the review) and before the provider hangs up, I ask the patient and family if they have any questions for the provider. This process allows for a complete breakdown of the typical changes that happen with hospice. Furthermore, it builds trust with the patient and family that this is their journey and we are transparent in supporting them.
Then there’s the closing process with the patient and family, where education is provided on the next visit (typically the next day) that all future charting will be done in the home electronically (best practice), call hospice first, don’t call 911 and last-minute questions by the patient and family. If the questions seem to take longer than 15 minutes to address, I politely reinforce it’s been about an hour now, there’s a lot to sink in, and another nurse or I will be back tomorrow so we can start addressing those issues. By the way, unless I know 100% for sure the nurse visit frequency, I’ll let the family know that the nurse coming to the next visit will go over the nurse frequency (that gives me time when I am working on the rest of the charting to think about what’s best for the patient and family as well as consider what other patients live within reasonable driving distance of them if their frequency is once or twice a week).
Then it’s onto the other visits, eventually getting the physical papers to the office and completing the electronic charting. As I can, I call the appropriate pharmacy for the equipment, comfort medications, and any immediate refills the patient needs.
After a short break as an RN House Supervisor for a nursing home, I’ve been a hospice registered nurse case manager since April 2018. I love the field. Don’t hesitate to contact me if you have any questions, recommendations for doing anything differently, or want to discuss your hospice experiences.
Equipment I use or recommend:
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