Dying patients in skilled Medicare beds benefit from the kind of intensive symptom management that hospice would provide but cannot give in that setting. “That's where palliative care can help until the patient is through his skilled term and is appropriate for hospice,” Dr. Elnadry suggested.
As their consultation service developed, several benefits became apparent to Ms. Edwards and Dr. Elnadry. Hospice care in the nursing homes increased, and more patients have made the transition to the Medicare hospice benefit.
In addition, the nursing staff enjoyed heightened confidence in their assessment and symptom management skills, and felt more empowered to approach primary care physicians about symptom management for their patients, Dr. Elnadry said. She added that the nurses also have developed a higher regard for the input of their nursing assistants.
Before starting a service, be sure to plan for growth, Dr. Elnadry advised. “We had so much growth that we could not keep up, and it's not that easy to recruit people when you have a sudden growth spurt in the number of nursing home patients.”
Contracts have to be carefully worked out. Medicare Plus Choice plans often have specific hospice eligibility requirements, and sometimes will not allow hospice care if the Medicare Plus Choice program is paying for the nursing home bed, she added.
Finally, data collection is difficult when multiple institutions are involved. “If there is not adequate staff to collect data prospectively, access to data may be lost if the nursing home doesn't open its charts for review and data collection,” Dr. Elnadry said.
Meeting the Need for Palliative Care
Over the past 5 years, the nurse-practitioner model has helped Home & Hospice Care of Rhode Island, Providence, provide 350 consults and more than 1,200 nursing home visits, said Dr. Joan Teno, who is the collaborating physician with the hospice's nurse-practitioner palliative care consult service.
“This has been a very successful model for reaching a variety of nursing homes throughout the state, and our two nurse practitioners make it economically feasible to do on Medicare billing,” said Dr. Teno, professor of community health at Brown University, Providence.
“The nurse practitioners are wonderful because they shuffle very easily between the world of nursing and the world of physicians, and they're very successful at providing consults to nursing home residents who either need a pain and palliative care consult service or [would] come onto hospice services except for the financial disincentives under the skilled Medicare hospice benefit,” Dr. Teno said in an interview.
Dr. Teno added her voice to those who would like to see the Centers for Medicare and Medicaid Services improve benefits for interdisciplinary team care in nursing homes.
“And I would suggest that CMS [allow] an overlap program whereby people can access those skilled services and hospice at the same time,” she said.
The need to provide quality end-of-life care in nursing homes is mushrooming as the population of the country ages. A survey conducted in 2000 suggested that more than 40% of the chronically ill and dying spend at least some portion of their last month of life in a nursing home, according to Dr. Teno.
“We've found that [adding a] pain and palliative contract service is one means of addressing these concerns by providing very skilled nurse practitioners to provide consultations, teach and train the nursing staff, help mobilize the existing team in the nursing home, and then address questions around advance care planning and good pain management,” she said.