If you are a new nurse to hospice, one of the tasks you dread is doing an admission especially if you have scheduled visits the same day as the admission.

I would like 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.

  1. Try to have whatever paperwork your agency uses for the admission as filled out as possible, and in the order, you will go through it with the family and patient.
  2. Look at where all your patients live including the admission if you have visits plus the admission. Look up what you can on the admission so you can prepare yourself for SBAR medication and treatment recommendations, equipment needs, and so on.
  3. Call the patient and family before the admission to have them prepared for the flow of events as well as to have handy what you will need to complete the admission. My calls go something like the following: “Hello. My name is Peter, a registered nurse that will be coming over to admit _______. I am seeing various patients today, and 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 paperwork, physical and electronic, to go through and sign so we will need a smoke-free area where we can 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'm then going to do a head-to-toe assessment of your loved one; that takes about 15-minutes. After that, I will the medications you have out on the phone with our medical director (or provider) to see what they recommend keeping, changing, or discontinuing as well as which medications will be provided/covered by hospice. Pause. Do you have any questions?”
  4. When you arrive at the admission if the patient will not be signing their own consents, ask to spend just a moment with the patient to lay eyes and hears on them as well as introduce yourself. You are going to have admissions where the patient is in the process of dying when you get there or shortly thereafter. The compassionate thing to do is put the patient first and then deal with the paperwork.
  5. Then flow through the paperwork following the Keep It Simple and Smile (K.I.S.S.) approach where you highlight the key points, pay attention to the person who will be signing's body language for how fast and slow to go. Hospice is an elective service, and we need to remember they will get copies of everything. You are not a lawyer, let alone their lawyer, don't make it complicated by reading line-by-line or going into great detail. Stick with the major topics.
  6. After the consents and financial paperwork (including electronic) is signed, then go 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 will get those who ask for the alternative, and 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) and that family will have to do the CRP until EMS arrives… and most of the time the patient and family go the DNR route.
  7. 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. 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), (for any dementia, not just Alzheimer's), (), 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 do your assessment, please keep in mind that this information will provide the foundation for tracking declines to prove continued eligibility for .
  8. Now, it is time to the medications. For this, I recommend the two-pass method. As you grow in experience as a , 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 with them to see what they know about the medications and to get their thoughts on the potential changes. That allows me to know hot spots that need to be addressed in advance of the call vs. 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 major 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 by into the typical changes that happen with hospice. Furthermore, it builds trust with the patient and family that this is their journey and we are being transparent in how we support them on this journey.
  9. 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 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 like they will 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 I or another nurse will be back tomorrow where we can start addressing those issues. By the way, unless I know 100% for sure the nurse , 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 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 will be once or twice a week).
  10. Then it's onto the other visits eventually getting the physical papers to the office and completing the electronic charting. As I'm able, I do call in the equipment and for the comfort medications as well as any immediate refills the patient needs to the appropriate pharmacy.

I've been a hospice registered nurse case manager since April 2018, having a short break as an RN House Supervisor for a nursing home, and love the field. Please feel free to reach out to me if you have any questions, recommendations for doing anything differently, or just want to talk about your hospice experiences.

Equipment I use or recommend:

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Various articles with tips for nurses

Hospice Nurses: Admission Tips You Can Use Right Now

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