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The case for hospice in the skilled nursing setting

May 31, 2012
by Penny Kozak RN, CHPN
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After working for 15 years in skilled nursing care in New York and Massachusetts, the opportunity to work as an educator for hospice presented itself. As anyone who works in the long-term and skilled nursing field can attest, it is a hard, stressful and demanding area of expertise. The expression  “has almost as much red tape as a nuclear plant” explains it all. With the goal of working in the hospice field at some point in my nursing career, fate took control and opened the door.

Nine months after joining a hospice organization as staff educator, I was tapped to become clinical manager of a soon-to-be-created facility team. Hoping to capitalize on my years of experience in the LTC arena, the hope was to create and grow a team of clinicians with experience in long-term care that would be sensitive to what the staff in our facilities must handle every day and offer the best customer service to our residents, families and facilities.

While the first year was dedicated to building the team and fostering relationships through building trust, collaboration and finding the right fit for each facility, when the end of the year arrived, we found we had the foundation in place to grow our presence in these facilities. As our hospice is “open door,” you would think that the referrals would just fly in, but it really took some time to build the trust that we would deliver what we promised.

By the end of the second year, we had more than doubled our census in the facilities and also increased our team as well. While the organization has had contracts with all the facilities in our territory, we were not always able to get the referrals in order maintain a steady presence in them. Being fiscally responsible, we also could not just put home health aides in these facilities for eight hours if we did not have the patient caseload to support it. So what did we do?


All of the teams within our organization are interdisciplinary but in the LTC setting the term multidisciplinary is most often used to describe the team. While we are comprised of the RN case manager, medical social worker, chaplain, home health aide and volunteer, we really do interact in an entirely different model than multidisciplinary teams. Driven by the resident’s goal of care, this gives us the ability to move fluidly between each discipline to meet the needs of our resident's, families and facilities.

The most moving experience occurred in our first year. A patient had been on hospice home care for about a year and then was transferred to a SNF as her care needs could no longer be managed by her spouse. As the patient declined, the anxiety of the spouse became more prominent and was discussed frequently amongst the team members. When the call came from the facility that the patient appeared imminent, the MSW, chaplain and RNCM were all at different locations. The HHA was scheduled to see the patient later in the day but we were able to move her visit to an earlier time, allowing for the other disciplines to rearrange their schedules. As each clinician arrived, the patient and her spouse were able to have continuous support from the hospice team during the dying process without being overwhelmed with the entire team all at once. The facility was thankful for the support the team was able to provide the family.

This turned out to be the clarifying moment for this team. I realized that the team had really matured and were able to see the bigger picture of hospice and how they functioned within it. With no help from the clinical manager, the team had talked to each other to coordinate who would get to the bedside first, second, third, etc.


Our second year we really focused on collaboration with our facility staff. I would like to say we had it down perfectly, but the reality is that it is an ongoing process. Staff turnover can be high in SNFs, and establishing relationships takes time, so losing these relationships can be defeating. The team has realized that because of our location, people move around the area but do not leave, so the odds are that you will be able to resume your relationships in a different facility at some point. This is where the art of collaboration is so crucial. The team has worked hard to make the word collaboration part of their usual vocabulary. Walk the walk not just talk the talk. Phrases such as "our shared patient" and "what do you think about trying this medication" have helped build these partnerships. Treating every facility as the resident's home and being professional are the expectation of the hospice team. Scheduling monthly clinical meetings and attending quarterly care conferences keeps the resident’s plan of care in the forefront for both the hospice team and the facilities team.