And there isn’t much difference, really -- until you check the into the details.
Different folks, different strokes
What happens when you call three different hospices and ask general questions about services they provide to patients? You will hear the same recording x3.
That does not mean it it doesn’t matter which one you choose!
Although hospice programs are similar, the details, could become a big deal for your loved one, are what sets them apart.
Don't get me wrong: Most hospices provide excellent care to the average patient.
The differences come when dealing with the rare patient or rare situations. You never know which patient is going to be average and which will present something rare.
I’ve seen quite a few hospice patients, and would not ever attempt to guess at which one is going to surprise me tomorrow.
If your loved one falls into the rare category, I hope you find the right end of life center and will provide tips on how to do so.
Tips before signing up
Learn as much as possible about the hospice before you sign up, using as many resources as possible.
The first phone call to the hospice is important, with things said during that five minute call that may influence your decision.
Keep in mind that admissions are the are the lifeblood of any hospice company. When you call that company, the person you are talking to becomes a hospice sales person.
They want your business and will do what is needed to get it.
If you ask for something that is a little beyond the hospice norm during that initial phone conversation, you will probably get a "yes, I can do that."
That small detail could make or break the deal.
Ask for that special request a month after you sign up it will be much easier for the staff to tell you that hospice doesn't usually do that kind of thing.
Once you have signed on and built relationships with the staff, you, more than likely, are not going to leave for another hospice.
Please make sure you ask questions and get promises before you sign you or your loved one up.
Talk to the administrator
During your phone call, ask to speak to the administrator, who is in charge of the hospice. You don't want the office manager because he/she does not have the authority to make the promises.
Explain that you or your loved one will need palliative care and you had a few questions for the administrator.
Any promise you get from the administrator will stick. And if the administrator refuses the call, find a smaller hospice.
Speaking of size ...
The size of a hospice is dependent on many factors and can determine the quality of patient care.
I like to find out who owns the hospice. This will provide some insight into patient care.
If they are a conglomerate, they may have a vested interest in their stockholders and investors. This means they may be more interested in making money, than on patient care.
Find out how many offices they have and where they are. This is important for three reasons.
1. Most states limit an office's territory.
Example: My office is allowed to admit any patient that lives within 50 miles of the office in any direction.
If it is 51 miles to your house, I can't help you. To expand the area that a hospice can cover all you have to do is open a branch office.
Each office has its own 50 mile radius, so by opening a branch 49 miles from the home office you can serve patients 99 miles from the home office.
You want to work with the home office. The nurse at the home office has direct access to the person who makes the decisions. Branch offices rarely have any employees who make business or financial decisions.
Those offices are only staffed with clinical employees who must call the home office to get answers to business related questions, which leads to the second thing you must understand.
2. Telephone communications can be cruel, heartless when compared to face to face.
If a nurse walks into the administrator's office and asks for something that is good for the patient but bad for the check book and the administrator tells her no, then the administrator will have to look her in the eye every day knowing that she thinks he's a greedy heartless SOB.
If the nurse calls from an office that the administrator almost never visits and asks the question, then he don't have to worry as much about dirty looks or lost respect of a coworker.
The more detached the administrator is from the patient, the easier it is for he/she to lose perspective on importance.
3. Cream rises to the top, which is always at the home office.
The head nurse at the home office is always the boss of the head nurse at the branch office.
As a nurse gains experience they are naturally going to gravitate toward the home office.
Sure, there are exceptions to this rule but generally the home office is going to have better staff than the branch office.
If you are choosing between two hospices and one is a home office and the other is a branch, choose the home office.
I am not talking about where the office is located.
Many hospices operate out of some seedy buildings and neighbourhoods.
Many hospices operate out of houses instead of office buildings. You should pay no attention to what the office looks like or where it is.
What is important is the location of the on-call nurse. You need to know how far it is from the on-call nurse’s house to the patient’s residence. This is important.
It is common that a patient will wake up in pain, have seizures, fall out of bed, stop breathing, or have any other medical complication while on hospice service.
If this happens at 3 a.m., the amount of time between when the problem starts and the solution ends with when the on-curse gets there.
Make sure there is always a duty nurse close to you or your loved one.
If you live in the same town as the hospice office, then you should make sure that their on-call staff lives in town also.
But remember: Picking a local hospice is useless if they hire on-call nurses that are not local.
If the main on-call nurse lives 30 minutes from town, then you’ll have to wait at least that long before help arrives.
There may not be a hospice in your area that can promise that the on-call nurse will live close to you, but if there is then that is almost always going to be the hospice you should use.
To summarize: Where the on-call nurse lives is probably the biggest thing that you need to know before making your hospice decision.
I’d rather use an unethical/money grubbing hospice that can promise quick response time than a great one that will make you wait an hour before they can get you.
If you are choosing between a 15 minute response time and a 45 minute response time, it should be a no-brainer decision.
Do pharmacies matter?
Traditional pharmacies are retail pharmacies. Closed door pharmacies do large scale contract work, with nursing homes, hospices, and mail order insurance plans.
You place the order via a phone or website, the pharmacy fills it, and mails the drugs to you. Emergency orders are mailed next day.
Don't go to a hospice that uses a closed door pharmacy unless the pharmacy is in the same city as the office.
Here's why: With a closed door pharmacy, the drugs will make it into the mail that day and arrive at the hospice office with the next day's mail.
A local pharmacy can fill the prescription while the nurse waits. The patient gets the drug quicker -- about 24 hours quicker.
But some hospices work with local pharmacies for emergencies and used closed door for routine medication refills.
You need to make sure that your hospice can get their hands on the medications you need quickly.
Most hospices have a 24/7 contract with their pharmacy, so they can get orders filled anytime. You should make sure your preferred hospice has that type of access to their pharmacy.
Many patients never need a prescription filled at midnight, but those that do deserve to get their meds quickly.
Why size matters
No matter what anybody tells you, size does matter. You don’t want a hospice that is too big. You don’t want a hospice that is too small.
You want a hospice that is just right.
The more patients one person oversees the more they become numbers and not real people.
If the person who is making big decisions about your care doesn’t know you or much about you, then you are not going to get anything better than routine care.
Hospice patients often want or need something special or out of the ordinary; the larger the patient load the less likely that is going to happen.
Small hospices do awesome things for patients because they can focus intensely on one patient, but when the wheels fall off the bus, a small hospice can get in real trouble quickly.
What is just right? I don’t know.
I have no doubt that large hospices can give great care. It just takes a lot more effort on their part to keep everything personal.
I want to talk about how much attention you should expect and who you should expect to get it from.
First, frequency of visits. Your nurse should visit at least twice a week.
Any nurse that thinks they can keep up on a hospice patient’s condition by visiting once a week is delusional.
Find a hospice that promises two nursing visits a week. It shouldn’t be too hard.
Second, find out who makes the visits. The question you should ask is if the same nurse will visit every time.
There are two different theories on how to use nurses. As with everything in hospice one is best for the patient and one is best for the pocketbook.
The theory you want your hospice to have is the theory that believes that having the same nurse seeing you every time generates better care.
There are things that only an RN is allowed to do, and most of those things are only done once every two weeks.
A good hospice has the RN make every nursing visit. That keeps them as up to date as possible.
A bad hospice has the RN make one visit a week and an LPN make the other.
While this is better than those that offer only one visit a week, it is still not good enough.
The biggest thing a nurse needs to know about a patient is what is normal.
Some have high blood pressure, some low, some are 98.6 temp every day, some are a little lower, some are short of breath at all time, some are not.
For a nurse to know when something is wrong, they have to know what it looks like when it is right.
The only way to find that out is for the same nurse to see the patient every time.
Now, an RN makes about $5 an hour more than a LPN so there is great pressure from the bean counters (especially in large corporate hospices) to use LPNs as much as possible.
In those situations case managers may take care of 20-30 patients instead of the 12-15 I suggested earlier.
I have nothing at all against LPNs, but for the sake of consistency, you should choose a hospice that doesn’t use many LPNs.
You want the same nurse to come every time. The only way that will happen is if RNs make all the visits.
The routine use of LPNs is an indication that the hospice is taking care of the bottom line at the expense of the patient.
There are two more parts to this series. Next, find out why staff recomendations matter.
Staff recommendations matter
- Ask the nursing home staff who they recommend.
Usually they will have one that they use more than others or one that they think is best.
The downside to this is that you have to make sure that the staff member you are talking to doesn’t moonlight for the hospice they are recommending.
It is common practice for a hospice to hire a nurse from the nursing home to do some part time work. Obviously, someone on the payroll of a hospice isn’t an objective observer of which hospices are good and which are not.
- Ask the nursing home staff if they can tell you the name of the best nurse from the hospice.
Once you have that name, you can ask specifically to have that nurse Case Manage your loved one. This will help you avoid getting the rookie or the slacker.
If you tell the hospice up front that it is important to you that you have a specific member of the staff, they will grant the request if it is at all possible.
Remember, they want your business.
Notice in number one that I said the staff will either have one they like or one they think is best.
Those two things don’t always go hand in hand. Nursing homes often judge hospices by how much of their work they can push off on the hospice employees.
Hospices that hold their ground and make the nursing home do their job are not always popular with the nursing home staff, but they are often good.
Ask more than one staff member at the nursing home and ask people on different shifts.
The night nurse will know if the hospice on-call nurse comes quickly, while the morning nurse will know if the hospice Aide shows up on time and does the job well.
Ask around and see what you find out. It may not be the best or most objective advice you ever get, but you’ll learn a thing or two about your options.
What doesn’t matter:
- Membership in NHPCO (membership available to anyone)
- Membership in state hospice organization (membership is usually available to anyone)
- CHAP or Joint Commission Accreditation (programs that only provide hoops to jump through that often don’t have much to do with ensuring quality patient care)
- Specialty accreditation for nurses or other staff members (Letters after someone’s name rarely prove more than that they attended a class and took a test)
What does matter:
- Medicare Certification (the baseline requirements for a hospice to be able to do a good job)
- Do they take your insurance? Ask them don’t just check your book, because hospices can usually get a one-time contract for a patient.