Hospice in a Skilled Nursing Facility

Routine Hospice Services (one of the four levels of hospice cares) can be provided anywhere that the patient calls “home”. This can be a private residence (owned or rented), a group home, assisted living facility, CBRF (Community Based Residential Facility), Memory Care Unit, or Skilled Nursing Facility (Nursing Home).

For Hospice Cares in a Skilled Nursing Facility (SNF, or Nursing Home), there sometimes can be a misunderstanding as to the expectations of hospice services. Routine Hospice services are a level of service that is provided ON TOP of whatever services are already in place at the facility. For example: At a Skilled Nursing Facility, there are caregivers/CNAs/residential aides there for all of the residents. There are also nurses at these facilities 24-hours a day (thus the reason it is called a “skilled nursing” facility). When a facility resident signs onto hospice services, the resident should continue to receive all of the cares that he/she regularly receives from the SNF staff (showering, feeding, bathing, toileting, etc). Hospice will add ADDITIONAL services to the services already in place. Hospice DOES NOT replace any of the services and cares the resident is already receiving at the facility. If HHA (Hospice Aide) services are added to the Hospice Plan, the HHA provides ADDITIONAL cares on top of what the facility is already providing. HHAs are CNAs (certified for providing cares) but they will not take the place of the facility staff caregivers role.

Caregivers and nurses, at the facility where the hospice patient resides, should continue to provide their regular routine facility cares for the hospice patient. The hospice nurse will make regular visits to review medications and perform regular assessments watching for decline or changes in condition. The hospice nurse will provide facility staff education on hospice cares, medication administration, and on end of life cares as the patient starts to decline in condition. The hospice nurse will also be in close contact with the family of the hospice patient, keeping them updated on changes in the care plan and changes in condition. Visits by the hospice team will vary depending upon the needs of the hospice patient (as the hospice patient starts to decline, the hospice team will be coming in more often).

It is the Facility Nurse’s responsibility to keep the hospice team up to date in changes, symptoms that may arise, falls that might occur, and with new orders received. It is the Hospice Nurse’s responsibility to check in/out with facility staff for improved communication and cares for the hospice patient. The facility nurse should call the hospice team whenever any of these issues arise. The facility MAR (Medication Administration Record) must match the hospice agency’s Medication Profile at all times. Care Plans should be updated frequently as the patient starts to decline.

THE ROLE OF THE FACILITY NURSE for a hospice patient in their facility:

• Continue to provide scheduled medications, follow the MAR
• Continue to keep up on the Care Plan for the CNAs and RAs at your facility
• Make sure that CNAs and RAs are providing the ADLs for the hospice patient
• Be familiar with PRN medications available for symptom management
• Ask the hospice nurse for further education if you are not comfortable with administration of PRN medications
• Assess for changes in the hospice patient and report to the hospice nurse
• Report any falls to the hospice nurse
• Call hospice before any lab work or lab testing
• Call hospice before sending patient out to the hospital
• Be aware of the patient’s code status (Full Code vs DNR)
• When the hospice patient passes, call the hospice team, not 911.

THE ROLE OF THE FACILITY CNA and RA for a hospice patient in their facility:

• Continue to provide the scheduled and routine ADLs
• Continue the shower schedule as usual
• Report any new areas of skin breakdown to the facility nurse
• Report any changes in eating to the facility nurse
• Report any safety issues to the facility nurse
• As the patient declines in condition, and becomes bed bound, end of life cares will be needed for the patient. The hospice team will educate you and your team on how to care for a patient who is actively dying.
• Let your facility nurse or hospice nurse know if you are uncomfortable with any cares for the hospice patient
• Let your facility nurse or hospice nurse know if you are having an emotionally hard time with the hospice patient declining in condition.
• When the hospice HHA/CNA arrives for their visits, stop and talk with him/her and let her know what you have done so far and what the HHA could help with during their one-hour visit with the hospice patient.

The hospice team and the facility team need to coordinate their cares together to provide the best end of life journey. Talk to each other – Frequently. When there are a lot of different people involved in cares, things can get missed and then the hospice patient suffers. TALK TALK TALK. Remember, this hospice patient is the center of this team.