Running head: HOSPICE COMMUNITY HEALTH CARE… 1

Hospice Community Health Care

Amanda Smith

Delaware Technical Community College

4/14/18
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Hospice Community Health Care

There are many different aspects of community health care. Hospice care is a relatively

new concept that focuses on noncurative, comfort care (National Hospice and Palliative Care

Organization, 2017). To be eligible for hospice two physicians must agree that the patient has six

months or less to live, and are showing signs of decline toward death. Hospice has become an

important part of the dying and grieving process in the United States because of the services it

provides. I wanted to learn more about hospice healthcare so I chose to complete my practicum

hours at the Delaware Hospice in Newark, DE. The priorities of care for this population are

comfort, and a greater holistic view of the overall being of the patient and family members.

Delaware Hospice provides services to the Delaware and southern Pennsylvania areas,

and is a nonprofit company. During the process of conducting a windshield assessment, it was

noted that the state of Delaware, while spanning a small area, is home to a very diverse

population. For example, the entire state of Delaware can be traveled in 2.5- 3 hours. There are

two large cities, Wilmington and Dover, and much of the area in between is rural or suburban.

Delaware is an area where you can drive 5-10 minutes down the road and be servicing a very

different type of people. While conducting the windshield assessment, it was noted that some

areas had big houses, large yards and multiple cars in the driveway, indicating area of greater

wealth, while other areas had small houses or apartments in the middle of a small city with few,

older model cars and signs of a lower social status. The patient population associated with the

Delaware Hospice in Newark, DE, live mostly in suburban or small city areas. The area serviced

in Pennsylvania seemed largely suburban, but there were certainly differences in wealth and

social standing there. Medicare appeared to be the most used insurance company for this

population.
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The role of the nurse in hospice is to be the case manager and facilitator of care for each

patient and family enrolled with this service. The nurse communicates needs of the patient and

family to the physicians, social work, and any other appropriate service. The nurse also

determines what times the care aids will assist the patient and what care will be provided at each

visit. The nurses assesses their patients at each home visit, performs wound care as needed, does

medication reconciliation and ordering as needed, and the nurse may pronounce in the event of

death. The nurses that are not case managers for patients, such as on-call nurses in the evening,

assess patients on a need basis, obtain orders as needed, and manage uncontrolled symptoms. In

hospice home care the nurse is an essential part of communication between all team members.

While speaking to my preceptor and conducting my own observation I determined there

are some needs for patients and families in the community who are enrolled in Delaware

Hospice. The first problem is that there is a gap of care for some patients and families. Patients

who are in hospice care tend to be a member of the geriatric population, and they may have

aging spouses or spouses who have already passed. In this day and age in America, there are

fewer families able to give the time and care for an aging family member. In most households,

not only does the husband work, wives are now working full or even part time jobs, and are

raising children. Statistics from the U.S. Department of Labor show that women’s participation

in the labor force has climbed from 32.7% in 1948 to 56.8% in 2016 (DeWolf, 2017). The

patient may not have any children, which is going to be more and more common as people who

decided not to have children for any number of reasons become elderly. During hospice care

there is only so much time that aid services are paid for by Medicare. According to my preceptor,

aids at Delaware Hospice are paid for by Medicare for one hour a day, five days a week. The

other 23 hours of the days are up to the caregiver in the home, whether that is a paid service, a
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spouse, children, etc. That is a long time for a patient and family if they are not able to give

correct, safe care. Patients in hospice who are declining become less and less able to move on

their own, if they are obese or require extra care for any reason there is a high possibility of

caregiver burnout, injury, and decreased care for the patient. Delaware Hospice has an inpatient

facility in Milford, DE as an option, but it is usually for patients with severe, unmanaged

symptoms and not everyday use. There is only so much Medicare and other insurances will pay

for.

SMART goals to reduce the risk of inappropriate care are 1) have primary caregiver

demonstrate care used in the home (turning, toileting, etc) at the end of each nursing visit and

verbalize comfort with the action. The nurse should evaluate what tools they use to accomplish

the care (draw sheet, side rails, proper body mechanics, one or two people, etc) and decide if

there is a more efficient and safe way to do care. The nurse should teach about resources of care

if the action was undesirable and the caregiver should verbalize understanding and/ or

demonstrate. If care is not able to be performed safely and/ or on a regular basis the nurse should

give referrals for home care. A second SMART goal for this issue is that the patient and

caregiver remains injury-free throughout the process and should be assessed during each nursing

visit. This can be accomplished by getting equipment from hospice to lessen risk of injury, such

as wheelchairs, walkers, and hospital beds.

If goals are not being obtained the nurse should have referrals for respite or home care

services besides hospice that the patient and family have the potential means to support. This

may need to be implemented early in the hospice journey, towards the end, or not at all if

caregivers are able to adequately manage. Some nonmedical home care services in this area are

Right At Home in Elkton, MD, Home Helpers in Newark, DE, Comfort Keepers in Townsend,
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DE, and Your Own Home in Greenville, DE. Nonmedical home care is not covered by Medicare

so there needs to be discussion about the costs and the pros and cons to having nonmedical home

care (Centers for Medicare and Medicaid Services, 2017). Ideally, sometime in the future

nonmedical home care will be covered by insurance, but for right now some suggestions to

affording home care is to refinance their home, sell assets the patient may not need anymore, or

take out a home equity loan (Brooks, 2016). Other suggestions for this include networking by

asking friends and other family (for example, their local church) if anyone would be willing to

donate time for care, and negotiating a price with a home care agency (Brooks, 2016).

Sometimes caregivers will agree to lower their fees, which would decrease the overall cost.

Unfortunately, even this is not enough in some cases and the family may just need as much

support as possible from Delaware Hospice when the nurses and aids visit.

Evaluation for interventions should be conducted at every nursing visit. The family and

patient should be happy with the care being provided, from whatever source, and they should be

confident in their ability to pay for the services. If the nurse suspects there is a problem it is time

to determine the issue, set new goals, and find interventions for those goals.

Another problem I noticed during my experience with Delaware Hospice is many patients

and families are concerned about the use of morphine (Roxanol), even when symptoms

progressed to the point of needing it for comfort. There is a big stigma associated with the use of

morphine during hospice, and many narcotics in general (Welshman, 2005). Patients and

families are worried about overdose, addiction, and hastening death because of the use of

morphine (Welshman, 2005). From personal experience, my aunt had breast cancer and at the

end of her life she was on hospice care and she was so concerned about advancing her own death

that she refused to take morphine. While observing current patients on hospice I can see they
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have a lot of anxiety about the use of morphine, and the families are typically very nervous about

it as well. One patient described she “was worried if she took it at night she would never wake up

again.” Another patient’s family member said that they “didn’t want to give him any morphine

because he could become addicted and overdose.” In that case, the actual patient was in

respiratory distress and could have benefitted from the morphine.

Initially, it will be beneficial for the nurse to identify from each patient and family why

they are reluctant to use morphine and go from there because they may have different reasons.

SMART goals for reluctance to use morphine would be to ease the family and patient anxiety

about the usage of morphine during end of life care at the end of each nursing visit. The nurse

should teach about why morphine is very useful for care, especially for a patient with respiratory

distress or pain. The family and patient should verbalize understanding about the dosage, uses,

and benefits of morphine at each visit. This repetition will be beneficial if the patient enters a

crisis state because the family should be able to easily recall the how and why of administering

the morphine. Knowledge and understanding tend to allow people to be more comfortable about

a medication or task. Some families, especially when there may be many caregivers, concerned

about overdose should be advised to get a dry erase board or paper log to mark down times that

the patient received the morphine, what dosage, and when they are able to receive it again.

Evaluation of the SMART goals are tailored to each family. Ideally, the patient and

family will have verbalized understanding after the first educational session and continue to feel

comfortable with the use of morphine. But it is not unrealistic for many families to need

continuous teaching and reminding. The nurse can evaluate if teaching has been effective by

addressing the demeanor of the patient at each visit. Are they in respiratory distress? Are they in

pain? Has their pain increased? When was the last time they received or asked for morphine and
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was it effective? This is when a log may be very useful because the nurse can go over the log

with the patient and caregiver during nursing visits. If the patients pain and any respiratory

distress is being managed and the family and patient appear comfortable with the use of

morphine than the evaluation would be very positive. Although, patients who are expected to

decline may need to increase doses of morphine if pain and respiratory distress is not being

controlled and this may cause fresh anxiety about the morphine. In that case, the nurse needs to

think about the SMART goals and interventions and how they can continue to lessen anxiety and

apprehension about the use of morphine.

A third issue I decided to include is an issue that can plague nurses in any type of care,

but may become particularly strenuous in community care because driving can eat up time in the

day. This issue is giving too many patients to one nurse. At Delaware Hospice the patients are

assigned to the nurses by zip code to try to limit driving time. However, this can be a problem if

a lot of patients are enrolled in one zip code, or if a zip code assigned to a nurse is larger than

another nurse. Delaware Hospice does try to even out assignments among the nurses, so patients

may be given to nurses in surrounding area zip codes but even a small case load may be difficult

to manage if all the patients decline at once and have unmanaged symptoms. In 2005, Medicare

determined the average caseload of hospice patients was 12 patients per RN (Hospice

Association of America, 2006, pg. 10). Multiple nurses employed at Delaware Hospice said they

believe an optimal case load was 10-12 patients, depending on acuity.

This problem may not be as easily changed using nursing SMART goals because the real

problem stems with staffing and distribution of nursing care. However, nurses need to take it

upon themselves to set goals for their own care and, if they have a large assignment, make a plan

of care for each visit that is thorough and centered on that patient and family and is not
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excessively time consuming. Another goal could be to talk to the company and discuss concerns

about your caseload if you are having problems fitting each nursing visit in every week for the

patients, whether that be because there are too many patients on your assignment or because

many of your patients are declining and having unmanaged symptoms at the same time.

Evaluation of your nursing goals should come at the end of every visit for each patient,

and at the end of the working day. At the end of a visit the nurse should determine if they met the

goals they set for that patient and if they are on time with their schedule. The nurse should again

evaluate at the end of the shift if they accomplished what they set to do with their day. If there

are goals that did not get accomplished and time constraints have caused a set back the nurse

needs to reevaluate their goals and timing for the next day. The case manager nurse should

decide if the patient or care they may have missed needs to be addressed by the on call nurses in

the evening or if they will be able to attain it tomorrow. The evaluation should also take into

account if anything unexpected occurred. If a nurse is called to a pronouncement they may need

to be flexible and do what they can with the rest of their shift. Again, nurse to patient ratios can

be an issue in any establishment or community care and time management is a skill that is

acquired over time.

There are many challenges to community health care, and hospice certainly has similar

and different issues to other forms of community health. Gaps in nonmedical home care, the use

of morphine, and high patient to nurse ratios are not the only issues in hospice care and they are

probably not problems isolated to hospice care. However, they are very real to this population

and it is important for nurses to identify these issues and create SMART goals for decreasing the

impact these problems may have on patients and families. Proper, dynamic interventions and
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continuous evaluation done by nursing will go a long way towards exceptional hospice and

community care.
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References

Brooks, Steve. (2016, October 31). Horizon Healthcare. 10 tips for more affordable in home

health care. Retrieved from http://www.acehomehealthandhospice.com/10-tips-

affordable-home-care/

Centers for Medicare and Medicaid Services. (2017, April). Medicare hospice benefits.

Retrieved from https://www.medicare.gov/Pubs/pdf/02154-Medicare-Hospice-

Benefits.PDF

DeWolf, Mark. (2017, March 1). U.S. Department of Labor. 12 stats about working women.

Retrieved from https://blog.dol.gov/2017/03/01/12-stats-about-working-women

Hospice Association of America. (2006, March). Hospice facts and statistics. Retrieved from

http://www.congressweb.com/nahc/docfiles/hospicefs06.pdf

National Hospice and Palliative Care Organization (NHPCO). (2017, April 3). Hospice care.

Retrieved from https://www.nhpco.org/about/hospice-care

Welshman, A. (2005, July). U.S. National Library of Medicine. Palliative care: some

organizational considerations. Retrieved from

https://www.ncbi.nlm.nih.gov/pubmed/?term=Welshman%20A%5BAuthor%5D&cautho

r=true&cauthor_uid=16012417