Recently, one of Weatherbee’s senior consultants observed a hospice’s interdisciplinary group (IDG) meeting as part of an on-site mock survey of the organization. The 4-hour meeting included a review of all deaths and admissions that occurred during the prior 2 weeks, as well as a review of all existing patients on the hospice’s census. A total of 30 patients were discussed. The medical director, 4 registered nurses (RNs), 2 social workers, a chaplain, and the volunteer coordinator were present during the meeting.
At first blush, the consultant was impressed with the overall organization and flow of the meeting. The meeting followed a typical structure, with each nurse presenting a clinical summary of the patient’s status and current plan of care. Each patient’s electronic health record (EHR) was projected on a large screen during the meeting, and the team reviewed the documentation to assure accuracy and completeness.
As she listened, the consultant wondered how other potential observers would experience the meeting. For example: If she were a CMS or state surveyor, would she be impressed with the hospice, the team, and/or the meeting or would she cite deficiencies? If she were one of the patients or family members being discussed, would she be grateful she was under this particular hospice’s care or would their dialogue be upsetting? She listened more critically, and noted the following:
While the nurses took turns reading aloud the summaries they had entered into the EHR in advance of the IDG meeting, the rest of the team paid no attention at all – they were typing on their laptops, shuffling papers and passing them around the room, signing bereavement cards, having side conversations with one another, eating breakfast, leaving the room to fetch coffee, etc.
The RNs reported, many times, not having met their assigned patients yet even when the patients had been admitted 2 weeks prior. The consultant found herself wondering: Who completed the initial and comprehensive assessments? Who was monitoring the patient’s clinical/functional status and medication supply? How long did these nurses expect their patients to live; why was there no sense of urgency to assess and address patient/family needs?
A number of patients reportedly “declined all non-nursing disciplines." The consultant wondered: Why is this so? Was a particular case manager not explaining the interdisciplinary nature of hospice care to her patients/families? How could holistic end-of-life care be provided by a single discipline?
The medical director never uttered a single word; he merely signed the forms that were placed in front of him looking bored and disinterested. He left the room twice for extended periods, returning with a weary harrumph as he sat down. However, the meeting went on during his absences nonetheless. The consultant wondered: If his presence were not a regulatory requirement, would he even bother coming to these meetings? Why is he so disengaged? Why is he a hospice medical director?
The team was complying with requirements of 418.56(d) to: review, revise and document the individualized plan as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. But is the “letter of the law” all that matters? Is “paper compliance” good enough? As the patient-specific reports continued, the consultant became increasingly appalled by some of the information and commentary she heard. For example:
A patient on service for 5 days died without seeing a nurse after his initial admission assessment. The consultant wondered: Didn't he need additional nursing visits? Did he die alone? How, and how well, were his symptoms palliated? Did his family understand what was happening; were they prepared for his rapid decline and death?
Contrast the above with another patient who was on service for over 2 years. Her family reportedly “wasn’t prepared for her death at all.” The consultant asked herself: Why was the family unprepared after 2 years of hospice care? Was the family in denial with regard to the patient’s mortality; ignorant of her disease trajectory; possibly uninvolved or uncaring until it was too late? How does this happen when the team had so much time prior to the patient’s death to prepare the family with education and interdisciplinary support? Or, was this one of the patients who had “declined all non-nursing disciplines”? Even so, that wouldn’t explain the lack of preparation.
A relatively young patient with terminal bone cancer and contracted extremities reportedly needed a costly electric wheelchair for his mobility, positioning, comfort, and safety. The social worker suggested discharging the patient, letting him procure the device from Medicare, and then readmitting him so the hospice wouldn’t have to pay the cost. The consultant, cringing as the “F-word” came to mind (i.e., fraud), prayed that the social worker wasn’t serious and the team wouldn’t follow through with her suggestion.
A patient with end-stage Alzheimer’s disease reportedly “talks and talks all the time in her native German, but no one can understand a word she says…no one in the facility speaks German, and she has no family or friends…she always seems so happy to have company and just lights up whenever we arrive to visit her.” The consultant mused: How do you know this patient is appropriate for hospice care with a primary diagnosis of Alzheimer’s disease if no one can understand what she’s saying? How did you evaluate her as having a FAST score of 7b? She could be alert and oriented for all anyone knows (or in pain, or hungry, or in need of the bathroom, or frightened, or lonely, etc.).
A few patients reportedly had pain or other symptoms that required palliation, but the hospice nurses were “having difficulty” obtaining orders from the attending physicians and/or the facilities where the patients resided. The consultant wondered: Why was no one jumping out of their seat to object to these unnecessary – not to mention unfortunate and inexcusable – treatment delays? Was substandard care and mediocrity the acceptable norm at this hospice?
Next, a primary caregiver was described as being “totally selfish [because] he wants his wife to be awake and alert at any cost…he doesn’t want her doped up and drowsy.” The patient “is in extreme pain and needs palliation.” Although the RN obtained new pain management orders from the patient’s attending physician the prior week, she was not planning to implement the orders until “additional caregiver teaching occurs.” The consultant thought: Am I the only person in the room who finds this outrageous? If the patient has “extreme pain” and is in need of palliation, why weren’t the new orders implemented immediately with concomitant caregiver teaching?
Another patient’s family was described as being “totally and completely overwhelmed.” The social worker indicated, “the Chaplain’s visit frequency should be ‘TBD’ [to be determined]…but she [the patient] doesn’t really want spiritual care.” The Chaplain indicated she would call the patient to schedule a visit, and the social worker quickly quipped, “let her call you…you’ll soon learn in this job not to work any harder for your patients and families than they’re willing to work for themselves!” The consultant almost cried out: Why won’t you proactively provide support to patients/families when it is so clearly needed and warranted? Do you not understand your responsibilities and obligations as healthcare professionals? Can you not appreciate the fact that these patients have a limited life expectancy and, as such, time is of the essence?
Another patient was described as “having terrible hallucinations.” The RN said the caregiver didn’t want to medicate the patient [his wife] as, “they [the hallucinations] are her only friends…they’re a great source of socialization for her…she likes it when her friends come to visit.” The RN went on to say that some of the hallucinations were quite negative and disturbing to the patient. Although the nurse said she wasn’t in agreement with withholding the medication, she “would honor the caregiver’s choices.” The consultant wondered: Why hadn’t the RN attempted to address the patient’s hallucinations proactively with concomitant caregiver support and education? Could the patient be experiencing physical pain and/or emotional/spiritual distress? Would she benefit from the involvement of other disciplines? Do the RNs function as gatekeepers for, or barriers to, other discipline involvement? Do RNs always defer to caregiver wishes despite potential patient suffering?
Lastly, a patient reportedly “benefitted tremendously” from a recent inpatient stay for pain management at the hospice’s inpatient unit. The RN said she felt badly she “hadn’t suggested the inpatient stay months ago.” She went on to say that “it really should have happened months and months ago…he would have had much better quality of life…if only I’d known how much better he’d be feeling.” The consultant, almost despairing at this point, thought to herself: If it should have happened “months and months ago,” why didn’t it? Where’s the team involvement? Where’s the physician oversight? Why are these patients experiencing such treatment delays? How is this a high quality end-of-life experience? How is this "value-added" hospice care worthy of being billed to, and paid for by Medicare?
I hesitated writing this blog post and sharing this consultant's experience. Our goal at Weatherbee is certainly not "hospice-shaming" or adding to negativity surrounding the quality of care provided by hospices. But, unfortunately, the examples from this one IDG meeting are not atypical. As an industry, we have to figure out how to do better, how to improve the quality of care provided by hospices so patients and their families receive the very best care available at the end of life. I can only hope readers of this blog post agree that the quality of this hospice’s care is, at best, highly suspect; at worst, substandard, dangerous, and completely unacceptable.
So, what’s the take-away here?
If you don’t already do so, observe an IDG meeting at your hospice. Listen -- with “fresh ears” -- to what your team members say, to how each discipline reports, and to how they speak about the patients and families under their care. Here are some questions to ponder as you observe your IDG meeting:
- Is the care that’s being offered and delivered truly interdisciplinary?
- Are all core members present and accounted for, and participating in a meaningful way?
- Are plans of care appropriate, and are they reviewed and updated at least every 15 days (or more frequently if the patient’s condition warrants)?
- Are visit frequencies appropriate and honored and based on patient need as opposed to staff convenience?
- Who’s leading the team, and is it the person who’s responsible to do so (versus a self-appointed and perhaps inadequately trained team member)?
- Are relatedness determinations, payment-related obligations, and other decisions appropriate, justifiable, and supported by clinical record documentation?
- Would you be proud to invite patients/families (or surveyors) to your IDG meetings?
- Would you be willing to refer one of your loved ones to your hospice?
- Would a surveyor praise you for having a meaningful IDG meeting, good patient/family outcomes, and excellent quality of care; or, would your hospice be in immediate jeopardy for negative outcomes that resulted in (or could have resulted in) harm to one or more patients?
I suppose it’s possible for a hospice to have a less-than-ideal team meeting and still deliver good care. However, given the patient descriptions cited above, it’s doubtful this is one of those hospices. Don’t let your hospice or the interdisciplinary team operate unchecked. The last thing you want – or your patients/families need – is a negative outcome that could have been prevented.
Thank you for reading this blog post. I look forward to your comments.
Use this free tool at your next IDG meeting.
Posted by Joy Barry, RN, MEd President and Co-Owner of Weatherbee Resources, Inc.