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Helping With Hospice Care

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Many assisted living providers offer hospice care, a service that can be invaluable to residents and their families in times of need. Here are several strategies for effectively coordinating assisted living and hospice care. 


Partnering for End
of Life Care
BY ANYA
MARTIN
Joining with hospice organizations enables
senior living providers to offer residents complete
care

Joan Linsky’s mother-in-law requires hospice care, but she
lives in an assisted living community. She loves her surroundings,
where she has been able to bring her own furniture, and family members
can even stay over. While she knows she is dying, she enjoys eating
lunch and dinner together with other residents, but if she’s feeling
tired on a morning, hospice staff can prepare her breakfast in her
apartment.

Many assisted living residents in hospice care continue to
participate in community activities. Linsky’s mother-in-law does not,
but she loves walking down the hall to have her hair done at the
hairdresser. “She said to me once I never thought dying could feel so
good,” says Linsky,
senior clinical liaison for Lowell, Massachusetts-based
Allegiance Hospice and Palliative Care,
one of the Northeast’s fastest-growing hospice providers.

Seniors move to assisted living because they want a home, so
partnering with a hospice means they can stay home through the rest of
their life. Many senior housing companies are forming joint
relationships or launching their own hospice programs to enable
residents to remain “at home.” The decision to partner with preferred
hospice providers assures consistency of care with your community’s
culture, and facilitates shared expectations between the community
staff and hospice staff. However, it also can be a powerful sales tool
if communicated well, perhaps even the key factor that differentiates
your community from the one down the street, she adds.

“If you have someone as alert and oriented as my
mother-in-law, she doesn’t want to be in a nursing home,” Linsky says.
“She thinks of herself as a well person.”

On the other hand, senior housing providers may be afraid to
tell potential and current residents and their families about hospice.
Linsky urges them not to be — that they are doing people a service by
informing them about hospice even if they don’t need it right now.
Anyone diagnosed with a life-limiting advanced illness has a legal
right to hospice care, and its medical services and equipment are
covered by Medicare.

People don’t want to think about death, but the key is
education about what hospice is and isn’t. “It doesn’t mean that their
place is going to be associated with dying because hospice is not about
dying,” Linsky says. “It’s about living.”

UNDER-USED
RESOURCES

When people are in need of hospice,
they fear giving up hope, she adds. “But when you are on hospice, what
you are doing is changing what you are hoping for. For most people,
they are hoping for a painless death and that they are not going to be
alone and isolated.”

Studies have shown that more people and families are utilizing
hospice care, but the average length of that care remains relatively
low, meaning that people aren’t utilizing all the benefits they could
be receiving from it — from pain reduction to emotional support.
According to the National Hospice and Palliative Care Organization,
1.06 million people sought hospice care in 2004, an increase of 110,000
people over the year before and a tenfold increase since 1985 when just
158,000 people used hospice services. Of patients being served, 65
percent are 75 years and older. And while the average hospice care stay
is 57 days, more than one third receive seven
or fewer days of
care.

“Generally speaking, it’s never too late, but the benefits of
somebody being on hospice for a longer period of time certainly
outweigh that of a shorter time period,” Linsky says. “The sooner
somebody is put on hospice, the more they can utilize those wonderful
benefits.”

Hospices can provide assisted living providers with the
training and tools both to recognize residents who become eligible for
hospice care and to educate those residents about the benefits of
hospice care. And senior housing providers can help hospice providers
with the referrals they need to assure people are getting the greatest
benefit from hospice.

Once a resident is put on hospice, Allegiance works closely
with the community’s staff to ensure the resident has everything he or
she needs. A hospice company should be familiar with Medicare rules and
prepared to work with senior housing staff to order equipment, such as
hospital beds and wheelchairs, that may be needed for the hospice
resident.

The senior housing community benefits from around-the-clock
support from experts in end-of-life care. The resident who receives
hospice care from a hospice company should have access to its entire
interdisciplinary team—nurses, doctors, social workers, home health
aides, and volunteers. (The latter is a Medicare
requirement.)

“Volunteers are an integral part of our team,” Linsky says.
“In an assisted living setting, they can take a resident for a walk,
read with the resident, maybe do crafts. The most important thing is to
visit with them so they are not feeling isolated. For a lot of senior
housing residents on hospice, even though the building has a lot of
activities, because of how they are feeling, they may not want to leave
their room. Having extra visitors is the best of all worlds.”

PARTNERING
SUCCESSFULLY

Because it operates more than 423
communities in 38 states, the District of Columbia, Canada, the United
Kingdom, and Germany, it makes sense for McLean, Virginia-based
Sunrise Senior Living Inc., to have forged
two national partnerships with two of the country’s largest hospice
providers, Miami -based VITAS Healthcare
Corp
. and Scottsdale, Arizona-based
VistaCare Inc. However, because the
company recognizes that each community is different, it also has local
and regional partnerships to give residents the maximum amount of
choice. And Sunrise does not mandate that a resident select any of
these hospice partners if a physician recommends otherwise or perhaps a
family member has prior experience with another provider.

“The ‘why’ is pretty basic,” says Gregg
Colon
, vice president for quality assurance and resident
care. “Our mission at Sunrise is to champion quality of life for all
seniors. Part of this is trying to provide a dying process that is as
compassionate as it can be.”

If a resident passes away on hospice in their Sunrise home,
the company considers that a “successful outcome,” he adds.
“Ultimately, we want people to be where they choose and not to be
forced or pigeonholed into a hospital setting.”

The number of hospice programs in the United States has
steadily increased, with 3,650 providers offering hospice services in
2004. How does one choose a partner? Sunrise developed its partnerships
so that the company could promise a high level of service consistent
with the quality residents expect. Each partner has to meet a list of
best practices the company developed as a standard — for example,
assisting in activities of daily living in ways that are
dignified.

“It’s a complicated business on both sides, so familiarity and
knowledge of each other’s practices comes in very handy,” Colon
says.

When a senior housing provider has a partnership with a
hospice provider, it also makes
it easier to develop consistent programs to train staff and educate
residents about hospice and dying with dignity. The training offered
can vary widely among hospice providers, Linsky says. So it’s important
to ask the hospice for specifics on what it can offer staff, residents,
and family members in terms of education. For example, Allegiance
offers a wide range of “in-service training,” including death and
dying, symptoms and hospice eligibility, living with advanced dementia,
cultural dimensions at end of life, advanced directives (for example,
explaining the differences between a health care proxy, power of
attorney and “do-not-resuscitate status”), and managing grief and
bereavement.

“You have to recognize someone who has a need for hospice
care. If you miss, that person may end up in a hospital or nursing home
and not be able to come back to assisted living,” says Holli
Hallmark
, senior director, clinical services development for
VITAS.

The training goes both ways, says Colon. Hospice partners
train staff on the dying process and Sunrise staff train hospice staff
on the company’s best practices. The process differs depending on the
provider and location, giving each community leeway to decide what
works best. It can be in a class setting or more one-on-one with staff
members of each trading information, but no matter the method, Sunrise
tracks to make sure training takes place.

Once a hospice partner is chosen, it’s critical for the senior
housing provider to set clear measures of what it considers a
successful partnership, Colon stresses. Those exact measurements are
key to tracking and evaluating whether the partnership is meeting
expectations for the company and residents.

“Maybe it’s the utilization of hospice, maybe it’s the number
of people that die at home in the community versus outside, or maybe
it’s the length of stay on hospice,” Colon says. “It’s important to set
those goals upfront and then measure and see how you’re doing to assess
if the program is truly effective.”

VITAS’ partnership with Sunrise works well because the two
companies share the same key values and culture, notes Hallmark. That
Sunrise has put best practices guidelines into writing serves as a
valuable checklist to ensure both parties are meeting and exceeding
expectations. While Sunrise has high expectations, the best practices
also show clearly the company’s commitment to hospice care and making
the relationship work.

LAUNCHING A HOSPICE
BUSINESS

San Juan Capistrano, California-based
Silverado Senior Living Inc. went a step
further in January 2004 when it rolled out its own hospice division.
Silverado launched the service at the same time it began its home care
business to provide a full continuum of care in the company’s market
niche — seniors with Alzheimer’s and other memory
impairments.

Today, the company has four individually licensed hospices,
two in southern California, one in Salt Lake City, and one in Houston.
About 50 percent of the 195 patients currently served live in
Silverado’s 14 communities in southern California, Texas, and Utah, and
the other 50 percent reside either at home or in assisted communities
run by other providers or in nursing homes. While the company continues
to specialize in memory-care, it accepts hospice patients in all
categories except pediatric.

To see the growth, Scott Robinson, Silverado’s vice president
of hospice, only has to compare these numbers to when he first came on
board with the company in October 2004. The hospice service had 30
patients, of which 20 were Silverado residents.

Going into the hospice business yourself is the ultimate way
to ensure that end of life care is consistent with your company’s
culture and care standards, but
it can also be an excellent source of new revenue for a company that
wants to expand via diversification rather than bricks and mortar, says
Robinson.

But before rolling out your own hospice service, consider
economies of scale. “Take a good hard look financially from a strategic
perspective and ask yourself what you want to accomplish with the new
service,” Robinson says. “It’s probably not [cost-effective] unless you
have a very large base of operations. If you’re serving five to 10
residents with hospice, you’re better off partnering because Medicare
will pay for the hospice costs but will not cover overhead.”

Evaluate your overall strategy and ask yourself the following
questions:

  • Is your reason for offering hospice primarily to
    serve your residents or service the community at large, too?
  • If it’s just your residents, what’s the cost
    benefit, i.e., how many patients do you need to have on hospice as an
    average census to break even?
  • What are the
    licensing requirements for hospice services in your particular area?
  • How long does it take to get a license?
  • Where can you share staff to control costs?

Because Silverado could use a lot of part-time employees for
hospice when its census was low at the beginning, it utilized staff
from its assisted living residences. Today, thanks to its rapid growth,
the hospice division has its own full-time staff.

Silverado Hospice provides
hospice care for approximately 55 percent of its residents who receive
hospice, but the company still feels choice is crucial and leaves the
ultimate decision about who will provide hospice to the
family.

And yes, Silverado Hospice partners with other assisted living
providers, too. In that relationship, Robinson says listening carefully
is key. “What do they like or don’t like about their current hospice
provider? If I’m the provider, I need to be open to criticism and be
forthright about being able to meet their needs.”

Those needs can be as simple as a nurse remembering to sign in
when she comes in the door or to find the director of nursing at the
community and letting them know you are there and check in about
changes in resident condition or even community schedule.

“The way I view it is the hospice is a guest in their home,
and we need to respect their home and that environment to meet the
patient’s needs,” Robinson says. He advises other senior housing
providers to look for a hospice with the same attitude.

Anya Martin is a contributing writer to
Assisted Living Executive. Reach her at [email protected].

Regulatory Note:
While
the goal of assisted living is to provide hospice residents with the
choice to live in assisted living communities, not every state permits
this. There are states that still have admission and discharge criteria
that prohibit assisted living communities from caring for hospice
residents. A goal of ALFA is to partner with the National Hospice and
Palliative Care Organization to eliminate this barrier to
choice.

Tips
for Choosing a Hospice Partner

Holli Hallmark
of VITAS recommends asking the following questions of a potential
hospice partner:

  • While the Medicare hospice benefit rules clearly
    outline what should be included by law, is the provider properly
    certified and licensed?

If yes, then can they can provide all the levels of care your
residents need? This should
include continuous 24-7 care for
acute symptoms so the resident won’t have to be transferred
to the hospital. VITAS has triage clinicians available 24 hours a day
in case of the unexpected, as well as runners who can be dispatched at
any hour, but not every provider will have these resources.

  • Does the hospice offer grief counseling and
    support groups for staff, residents and family members?

Sunrise made the latter desire clear by listing it among its
best practice requirements. When a long-term resident dies, staff who
have developed relationships with that resident mourn, too. VITAS
schedules memorial services in the assisted living community that other
residents can attend, when requested. The company also does “living
memorials where we bring the neighbors of the resident with the
terminal illness and they can share what they love about that person
when that person is still there to hear it,” says Hallmark. “It’s a
really special thing—for staff, too.”

  • Is everyone on board?

Hallmark says that everyone with the program—from the CEO
level down to area or regional leaders to the community—must buy in to
the program. Hallmark is the corporate-level liaison assigned to
Sunrise and meets regularly with company key decision-makers, but each
program should have a liaison both at the corporate and at the
community level. Conversely, the fact that Sunrise has a very specific
reporting process at all levels makes it easy for Hallmark or any other
VITAS staff member to know who to go to if an issue, need, or question
arises.

VITAS has kick-off meetings when it comes into a new community
where it hasn’t provided hospice services before. It also has developed
a resource manual for its staff including protocols for interacting
with Sunrise. “The fact they’re so consistent in the care they deliver
and the quality they maintain makes our lives a lot easier because we
know exactly what to expect,” Hallmark says.