8
Levels of Care
When working with patients and families, hospice nurses are often asked to make recommendations for patient care in the home and in other care settings. The focus of this chapter is on the role of the nurse in assessing patients’ needs, determining appropriate levels of care, and communicating with other members of the health care team.
After reading this chapter, you will be able to:
■ Assess patient care needs to determine the appropriate level of care
■ Differentiate the types of hospice care provided at each level of care
■ Discuss tools used to structure interprofessional communication during patient transitions
DETERMINING PATIENT NEEDS
Hospice nurses must make recommendations regarding which level of care is most appropriate for a patient and family on admission to service (see Exhibits 8.1 and 8.2). For some patients, home care is the most appropriate level of care because there is a caregiver present and the patient prefers to stay at home rather than transfer to an inpatient facility. In other cases, inpatient care may be most appropriate due to the lack of a caregiver or because it is in line with the patient’s preferences. The decision-making process for determining the appropriate level of care is complex and involves a series of questions and decisions on the part of the family and the nurse.
Exhibit 8.1
Assessment of the Patient’s Goals and Wishes
■ What is most important to the patient right now?
■ If the patient’s condition were to change, would he or she want to stay at home or go to an inpatient setting?
■ What symptoms or conditions would make the patient or family consider a hospital admission?
■ Does the patient have a living will? Is a POLST order written and accessible?
POLST, Physician Orders for Life-Sustaining Treatment.
Exhibit 8.2
Assessment of Care Needs
■ Is there a reliable caregiver in the home?
■ Is the home environment safe?
■ Can the patient’s symptoms be managed at home by the caregiver with the support of the hospice team?
■ Is the patient experiencing acute symptoms? Can the symptoms be managed most effectively in an inpatient hospice setting?
■ Does the patient already reside in a long-term care facility? Is the staff able to co-manage end-of-life concerns with the hospice team?
■ Can the patient’s symptoms be managed in the home with continuous care from the hospice staff?
After completing the assessment, the nurse, in consultation with the patient, family, and hospice team, recommends the appropriate level of care, which may include:
■ Routine home care: Care of the hospice patient is provided in the home with regularly scheduled visits from the hospice team.
■ Continuous home care: Continuous care is provided in the home, predominantly by nurses, but can be supplemented with hospice aides. This type of care is intended to support patients and families through crises on a short-term basis in order to allow the patient to stay at home.
■ Inpatient respite care: Care is provided within an approved facility for a short period of time to allow respite for the caregiver(s).
■ General inpatient (GIP) care: Care is provided in an inpatient facility to achieve pain control or symptom management that cannot be accomplished at home (Centers for Medicare & Medicaid Services, 2015a; see Part V for a review of Medicare regulations pertinent to GIP care).
■ Last 7 days: A change in reimbursement for hospice care took place as of January 1, 2016. This service-intensity-add-on (SIA) was designed to recognize that the care provided for a patient during the last week of life is intense and costly. According to the Centers for Medicare & Medicaid Services (2015b), in order to receive reimbursement in addition to the per diem routine rate, the following criteria must be met:
The patient’s level of care is “routine home care”
The date of care is within the last 7 days of the patient’s life
Direct patient care is provided by a registered nurse (RN) or licensed social worker
With the appropriate level of care determined, the nurse coordinates the plan of care for the patient. The interdisciplinary team meets regularly (at least every 15 days) to review and revise the plan of care based on the patient’s condition and needs (National Hospice and Palliative Care Organization, 2009).
WHEN A PATIENT DIES
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