Thursday, November 19, 2009

Hospice Upheaval

It never occurred to me until today that enrolling my patients in hospice could cause them harm and distress. What unfolded is what happens all the time but which I hadn't recognized could have such a negative effect. My patient had been receiving home health through one agency for chronic ulcers and short term home rehabilitation. She has been largely bed and chair-bound and I have seen her frequently on housecalls. Her condition had plateaued and with her strong desire not to ever return to the hospital and to live as comfortably as she could in her home until she died, we agreed it was time to transition to hospice. The previous home health agency did not have a 'sister'-hospice as part of their organization. So I enrolled her with one of the agencies I work closely with.


The intake by the hospice case manager was uneventful. All seemed well until I heard from her family that yesterday several men from several different DME (durable medical equipment) companies came in and out of her home to change ALL of her equipment: hospital bed, pressure pad, wheelchair, shower bench, oxygen and humidifier, etc. She was overwhelmed, distraught and felt she had lost all control of her life and her home. Hearing this I felt immense remorse and guilt. I already knew that many agencies have contracts with different DME companies. But I had never recognized that, of course, when hospice uses different companies from pre-hospice days, the equipment is changed over--necessitating a tremendous upheaval (physically and emotionally) for the client.

I wish I'd had the foresight to discuss the DME issues with the hospice case manager before this had occurred. Might we have been able to spread the visits so they didn't coalesce in a torrential downpour in one day? Or would there still have been an urgency by the DME companies and hospice to have everything set up promptly per their contracts? I don't know. I intend to discuss the case with the hospice. While patients in closed systems such as the VA or HMOs may not experience this, it's worth discussing for those of us who practice in the community and partner with different home health and hospice agencies. Who would have thought that something as 'mundane' as DME contracts could so significantly influence a patient's quality of life? Well, now I know better.

10 comments:

Chek Wong said...

We have a similar problem in Singapore. When a patient transitions from one service provider (home care, acute care) to another. A lot of information especially personal preferences, psychosocial status gets lost in this transition or translation.

I was thinking that sometimes we reduce patients to a series of check boxes of steps we have to go through. It gets the job done by audit standards but one may miss information on quality of life choices.

Helen Kao said...

Thank you, Chek, for your international perspective. In this case, the patient actually had excellent transitions of care because I and my Bridge team followed her at home, hospital, SNF and back home. The agencies we partnered with for home health and hospice are both agencies that provide excellent care and communicate with me regularly in person or phone. It is more the LOGISTICS and reality-check that her DME had to be changed over to whatever companies the hospice agency contracts with that created the upheaval yesterday. I agree that in the process we (myself, hospice, the DME companies) did NOT demonstrate patient-centered palliative-valued care. Addressing this system failure is what I will engage in with the hospice.

LeighSW said...

When we admit a new patient that already has DME in the home, we usually try to get a contract with that DME company, so long as the patient is pleased with the equipment. Sometimes that DME company won't give us a contract or won't charge a reasonable rate and in that instance, we do have to switch the equipment out. If that happens, we prepare the family for what this will mean and do what we can to make this a smooth operation. Some families want the old stuff out and new stuff in on the same day, others don't so we try to be sensitive to that.

Dan Matlock said...

Thanks for the heads up. I had never thought about this before.

Heather Shaw said...

Hi Helen

I have had a similar expereince and I too felt badly for not taking the DME upheaval into consideration. I think it's a learning opportunity for all of us.

Heather Shaw

Tim Cousounis said...

The flip side of this issue is, of course, that there are many instances when patients are not enrolled on hospice and remain on the home health benefit, primarily to avoid the HME issue. It takes skillful and adroit coordination and management to provide the patient (and family) with a smooth transition from the home health to hospice benefit - because most hospices are small and stretched financially, there usually is insufficient staff and time to provide this coordination. This issue is, unfortunately, one of many that adversely affect hospice patients and families because of the subscale hospice industry. In other words, most hospices are too small (not enough volume) to deliver services efficiently and with proficiency.

Carol Jessop, M.D. said...

Hi Helen,

Loved your comments, and agree with you that Hospice Services and Home Health Services need to consider this disruption. I forwarded your thoughts to the Hospice where I work as a Medical Director, and will see what our policy is....If it's causing this much disruption, we need to change it!

Carol Jessop, M.D.

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Hospice California said...

It is really a very good articles, informative also loved your comments, and agree with you that Hospice Services and Home Health Services need to consider this disruption.Thanks

Hendrix said...

I am glad to see others concerned on this issue. I have been in Hospice over 15 years and bought a small DME company in 2006. Our business is 90% Hospice. Recently, larger more competitive companies have been coming in underbidding us which has required several switch outs. (I hope they can provide the same quality service).
I've found the best way to handle this is for the acquiring DME to perform the breakdown and removal of equipment and placement of theirs. Arrangements should be made ahead of time between the DME's for exchange of their equipment. Good communication is a must. The switch out is not the patients or facilities deal and must be done in a polite, friendly, un-obtrusive way. Without exception, the transition is supposed to be smooth with no adverse affects. No more than two people should handle the job and those individuals need to be experienced and trained DME technicians.