At Texas Hospice, we occasionally have difficulty determining when a patient qualifies for continuous care (24-hour bedside nursing presence). The ONLY factor in making this decision is whether or not the patient’s status meets the medicare written guidelines:
· Continuous home care should be provided only during a period of crisis as necessary to maintain the terminally ill individual at home.
· A period of crisis is defined as a period in which a patient requires predominately nursing care to achieve palliation or management of acute medical symptoms.
· If a patient’s caregiver has been providing a skilled level of care for the patient and the caregiver is unwilling or unable to continue providing care, this may precipitate a period of crisis because the skills of a nurse may be needed to replace the services that had been provided by the caregiver.
· The hospice must provide a minimum of 8 hours of care during a 24-hour day.
· When ensuring the 8-hour requirement has been fulfilled, remember that the 24-hour day begins and ends at midnight.
· The care need not be “continuous.” For example, 4 hours of care may be provided in the morning and 4 hours may be provided in the evening.
· Nursing care must be provided for more than half of the period of care and must be provided by either a registered nurse or licensed practical nurse.
· Nursing care in the hospice setting can include skilled observation and monitoring when necessary and skilled care needed to control pain and other symptoms.
· Homemaker or home health aide services may be provided to supplement the nursing care.
But here are some situations that present in the real world:
- the patient’s physician insists on continuous care (it is difficult to tell any physician s/he is wrong or wrongly informed, especially if they consider themselves to be a “hospice physician”)
- the family, having developed a false idea about continuous care, demands it
- the assisted living facility staff demands it
- many competitors provide it to all their patients who are dying (inappropriate) thereby falsely educating the public and medical community
The guidelines imply that continuous care is really crisis care. However, there is a little wiggle room: continuous care may be provided when a caregiver, who was providing a skilled level of care, withdraws, and this withdrawal may precipitate a crisis. That seems a least a little ambiguous.
I have heard on other blogs that some state regulators consider continuous care inappropriate anytime when the patient lives in a skilled nursing facility.
What is needed in the Dallas/Fort Worth area is better public education concerning hospice care, and better leadership within the hospice community.
But this leadership and education must be understood against a backdrop of money-making and marketing. Hospice agencies conduct continuous care within a high profit margin. And, the agencies sometimes advertise their willingness to use continuous care anytime a patient is actively dying.
