Tips for Selecting a Hospice

If you or someone you love is referred to hospice care, you can choose a provider that best matches your needs and values. Sometimes, there only one hospice serving your community; but quite often, there are many hospices to choose from. There are basic services mandated by state and federal guidelines, but how the basics are administered differs among hospice providers. In addition, you may want to explore services provided that go "beyond the basics".

So, how do you find the most hospice that is right for you and your family?

You gather information about them in a number of ways, just as you do with other healthcare professionals you use -- physicians, dentists, hospitals, nursing facilities, etc. You ask people for recommendations, you read about them online, you call their offices and ask questions, and/or you pay them a visit.

We have pulled together a list of topics and questions for you to ask as you explore the hospice options where you live. What you learn will guide you as you make an informed decision when choosing hospice care.

Recommendations & References

Ask people with whom you are connected if they have had experience with certain hospices. Word-of-mouth references from people you trust (healthcare providers, friends, family, co-workers) can be helpful in forming an overall impression of a hospice agency.

Ask the hospice to give you references from professionals such as a hospitals, physicians, and social workers who have used their agency.

Location & Years of Service
Ask if the hospice has an office in the county in which you live. It speaks to the hospice’s commitment to the local community, and their ability to respond quickly to your needs.

Ask how long the agency has been doing hospice care. Years of service is an indication of stability, and sometimes the hospice is an add-on to a company that has been around longer, providing other kinds of healthcare goods and services. As a point of reference, the first hospice opened in the United States in 1974, and many hospices began operation in the 1980s. Hospices have opened continually since then and are still being opened every year.

Medicare Certification, State Licensure, and Accreditation
If the patient is a Medicare beneficiary, then Medicare certification is essential so that the patient’s Hospice Benefit can be used for reimbursement.

The hospice should be licensed in the state in which it is operating if the state requires it.

Accreditation by an independent healthcare accrediting group (such as JCAHO, CHAP, or ACHC) is not required and, without it, a hospice can still provide stellar service. What it means, however, is that a third party has reviewed the hospice’s operations and determined it meets a certain standard of care.

Medical Professionals & Volunteers on Staff
You will want to look for these specific things with regard to staff:

• A Medical Director who is either full-time, or who is—or has staff who is—available during evenings and weekends.

Ask if the physicians are hospice or palliative care certified. It represents a level of expertise that reflects well on a hospice.

• Nurses – Ask if a nurse is assigned to each patient as their case manager? It is preferable to have a RN (registerd nurse) managing the hospice team’s care of the patient and family.

Ask how many staff nurses have earned certification in their hospice and palliative care field (CHPN is the designation you’re looking for). It shows that these professionals have taken the time and effort to become specialized in their field, and a hospice agency that has several of these is likely focused on quality.

• Nursing Assistants, or Health Aides, sometimes referred to as CNAs (Certified Nursing Assistants) – These trained professionals help with a variety of toiletry and housekeeping needs, and this varies quite a bit. Find out what they do, if they can be scheduled, and if they are on-call for weekend visits.

• Social Workers and Chaplains – The hospice should employ them fulltime, as you will want access to them to some degree at some point.

• Bereavement counselor – The hospice should employ counselors who are available to patients and families both before and after the death of a loved one.

• Volunteers – One mark of a really good hospice is a large number of volunteers who are well-trained to do a variety of patient- and family-related services. This might not be important to you in the beginning, but it could be at some future point.

On-call Nursing Staff
One of the most important questions you can ask is where the on-call nurses are located and how large of an area the nurses cover at night and on weekends. You are looking for assurance that they will be responsive to your needs “after hours”.
Telephone Response
The hospice agency should have a 24-hour telephone number that you can call if you have questions or concerns, or in the case of an emergency.

Ask: How do you respond to phone call during the day, and at night and on weekends?

Starting Services
You are looking for answers that demonstrate a quick response time that is sensitive to patient and family needs and handled by the appropriate clinical staff.

Ask: How soon after we decide to receive care can an admission to your hospice be done? Who will do the admission?

Levels of Hospice Care
The Medicare Hospice Benefit covers four levels of care, but not all hospice agencies are equipped to provide them all. Let's briefly take a look at the levels and why they might be important to you during hospice care:

Routine Home Care is the basic level of care and is used for the majority of hospice patients. If applicable to you, ask if hospice care can be provided in a skilled nursing or assisted living facility and, if so, which area facilities the hospice serves.

Continuous Care (or Crisis Care) is for patients having symptoms that cannot be controlled via routine care. Hospice staff stays at the bedside for a minimum of 8 and up to 24 hours a day to provide symptom management.

Respite Care is designed to give caregivers a break if they are burnt out or otherwise need a temporary break. Ask who the hospice agency has a contract with. (Nursing facilities, hospitals, and hospice inpatient units—also referred to as an IPU or a Hospice House—all provide this service.)

Inpatient Hospice Care patients are admitted to a hospice house, nursing facility or hospital for a short time where they can receive ‘round-the-clock care from medical staff until symptoms are under control. Ask who the hospice agency has a contract with.

You should ask your hospice agency which of these levels they can perform, and where they take place. Ideally, a hospice agency should have a contract with a hospice house, nursing facility or hospital to provide inpatient care and respite care in the event a patient needs it.

Hospice Inpatient Unit
Some hospices have their own inpatient unit (IPU), or hospice house where patients can have access to respite stays and inpatient care if needed. There is also a third level of care within a Hospice IPU, and it is referred to as “Residential” or “Transitional” care. This type of care allows for a short-term stay for patients who cannot be in their own homes and need time to make other arrangements. The care is covered under “Routine Home Care”; the patient is responsible for the cost of room and board.

Ask if the hospice has their own inpatient unit or hospice house and what levels of care are provided there?

Individualized Care Plan
The hospice should create an individualized Care Plan for each patient and family based on the input of the patient and family and each of the hospice team members involved in the care.
Cost of Hospice Care
Medicare, Medicaid and most private health insurance companies cover hospice care. and reimburse the hospice agency for all, or most, of the cost of care—including certain medicines, supplies, medical equipment, and prescribed therapies.
While not the most important factor in choosing a hospice agency, it is worth knowing which pharmacy they use and how close it is to you. It’s important to know how easy it will be to get medications when you need them.

Ask: Which pharmacies do you work with?

What Other Services Do You Provide That Others Have Found Helpful?
You are looking for things such as Alternative Therapies (pet, music, massage, art, and/or aromatherapy); Volunteer Hairdressers and Manicurists; Specific Faith Support and Services; and Family Grief Support Groups. Even though you are not now, and may never be interested in any of the “extras”, it is good to know which hospices go “above and beyond.”
  • Does your agency provide pediatric hospice care?
  • What if I don’t like the hospice I choose? If you are not satisfied with the services that are important to you, you can change hospice providers. Ask how the hospice deals with this just in case it becomes necessary.
  • Does your hospice measure and track quality? You aren’t looking for in-depth details, just the assurance than the hospice does evaluate its own performance and take steps to improve it.
  • How often will the nurse visit?
  • What is the average number of patients the nurse is caring for? The average ratio is 12 – 15 patients per nurse case manager.
  • Do you require that I have a Do Not Resuscitate order (DNR) in place?
  • Which insurance payors do you have agreements with?
  • Do you have a Palliative Care Program?
  • What do you offer that is unique to your hospice that other hospices don’t offer?

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