Tim Mullaney

Easier said than done.

That phrase often pops into my head when I read the latest long-term care research. For example, it occurred to me after the recent news that working with a hospice provider can help skilled nursing facilities reduce hospital readmissions across the board.

Great finding, but perhaps harder than it sounds to operationalize, I thought. To get a firmer grasp on the challenges in forging a strong SNF-hospice relationship, I attended an education session at the LeadingAge conference in Nashville last week. Jeanne Dennis, senior vice president for hospice and palliative care at the Visiting Nurse Service of New York (VNSNY), shared many insights and much practical advice for providers, including the following tips:

1. Maximize the hospice “value add”

A nursing home administrator once praised the value of having VNSNY “sitters” for hospice residents, Dennis said. The hospice aides were simply offering companionship to residents and were not allowed to do any other type of care, because the administrator did not believe that the facility’s license allowed for that.

In reality, VNSNY’s hospice aides receive specialized training and are not meant to simply be “sitters.” But enabling these aides to actually perform to the full extent of their training was not simple — it required educating nursing homes and carefully defining the aide role, Dennis explained.

“Nursing homes at first were skeptical, but the integration of these workers into the day-to-day caregiving of the nursing home has been very, very positive,” she said.

Role definition is crucial, she emphasized. The VNSNY hospice home health aide is “value-added,” not a replacement for a certified nursing assistant. The nursing home workers still need to execute their plan of care, and the hospice aide offers additional support, such as massage or more frequent bathing. While there may be “some gray area,” the hospice aide should not be picking up CNAs’ slack. It should not be a “you feed because I don’t have time” scenario, Dennis said.

2. Be sensitive to resistant SNF nurses

It’s natural that SNF caregivers might resent the appearance of a hospice worker in the facility, Dennis noted. In some cases, nurses and aides at the facility have been caring for a resident for years, and feel they are capable and called to provide end-of-life care as well. How to persuade these staff members to work well with the hospice aide? Dennis offered a few suggestions.

One is to focus on the hospice worker’s special expertise in pain management. Managers can point nurses to data from Brown University’s Susan Miller, Ph.D., and Vincent Mor, Ph.D., showing that hospice offers “state-of-the art pain intervention.” SNF nurses often can appreciate that they do not have such an “exclusive focus” on palliation.

A focus on the family also can be very powerful. An administrator might essentially communicate that the hospice worker is there to provide additional peace of mind for family members, and because the hospice might also provide extensive bereavement support for the family. This might take the form of support groups or memorial services. Hospices also might help nursing home workers themselves process the loss of beloved residents, Dennis added.

3. Know some nuances of home vs. SNF care

Many people think of hospice as a form of at-home care. This goes for hospice workers, too, Dennis said. Some hospice nurses and aides got into this type of care with the expectation that they would be in people’s homes, and they are not necessarily comfortable going into skilled nursing facilities.

Part of this is that hospice caregivers can glean a tremendous amount of insight into a person’s values, priorities, interests and even their care preferences from the home they’ve created. In a SNF, the hospice worker might not have such a wealth of information. A nursing home worker who is sensitive to this issue can help fill in the blanks by sharing stories and important details about the individual.

That said, there are some hospice caregivers who excel in the SNF environment, Dennis noted. This is one reason that some hospice providers might have dedicated SNF staff who are separate from at-home caregivers. But other hospice providers might not have this arrangement.

Nursing home might be wise to learn how their hospice partners operate. It might help for triage purposes, for example. An attendee at the session shared this situation: A hospice worker has a caseload of mixed home and SNF patients, and she gets two late-night calls for assistance. The worker might go to the home first, thinking that the SNF patient has healthcare professionals at hand. But the patient at home might have highly capable family members providing constant care, while the nursing home might be short-staffed and trying to attend to many situations simultaneously. Communicating the facts on the ground can help a hospice worker prioritize most effectively.

Dennis’ presentation drove home the complexity of integrating hospice into a skilled nursing facility but also showcased the rewards — and I’ve barely scratched the surface here. For more details, you can access her PowerPoint presentation. Partnering with a hospice might not be a piece of cake, but expert advice like hers should make it a whole lot easier.

Tim Mullaney is McKnight’s Senior Staff Writer. Follow him @TimMullaneyLTC.