Thursday, May 27, 2010

Respite Admission Process

Medicare covers respite stays through the hospice benefit.  Generally, a patient is eligible to one 5 day stay per benefit period.  This is a helpful resource for primary caregivers, whether they're burned out and need a break or are simply going on vacation.  The patient will go to a Medicare-approved facility, such as a long-term care facility or hospice home, during the respite stay.  The hospice social worker sets up the respite stay.  I've been able to set up an emergency respite stay as quickly as 3 or 4 hours.  For a preplanned respite stay, a day or two's notice for the facility is generally enough, so long as they have a bed available.

There are tons of phone calls, faxes, and legwork going in to every respite stay.  There's a lot of waiting to hear back from various facilities.  A place may have a bed but they still need to review the patient's medical information before they will decide whether to accept them for respite admission.  Here is a behind the scenes glimpse of what goes on when respite is requested.

1. Review LTC facilities with respite contracts, check for bed availability, inform RN that family is requesting respite care.

2. Call family and discuss contracted LTC facilities, ask verbal permission to fax information to LTC facilities.
  • At this time, decide on mode of transportation.  Will the family transport the patient or will a Medicar or ambulance be necessary?  
  • If using Medicar or ambulance, explain that a specific time will be arranged with the facility and mode of transportation.
  • Check on specific equipment needs, such as oxygen, catheter, hospital bed, wheelchair, etc.
  • Explain to family that hospice pays for room and board for 5 days, medications related to the terminal illness, and transportation. 
3. Call Admissions Director of chosen LTC facility(ies) and ask availability.  Inform if patient is on oxygen or has a Foley catheter. If there is availability, then:
  • Ask if patient's MD is on their staff or if family needs to choose a physician on their staff.
  • Ask if the patient can bring their own medications
  • Get a range of possible admission times
  • Call family and have them choose a time, taking travel time in to account.  The facility may need the family to fill out some paperwork so they should factor this time in as well.
4. Fax the patient's record.  The following documents should be included: initial assessment, H & P, initial plan of treatment, care plan, face sheet, medication list, hospice consents, DNR (if signed), psychosocial assessment, last RN note, last MSW note, last ICC summary.

5. Call family and report above arrangements and:
  • Explain the time that patient is expected at LTC facility
  • Inform them that DNR needs to accompany patient, especially if they are not providing transportation
  • If they can take their own medications, they must be in original containers, clearly marked
6. Call the RN (or triage nurse if on the weekend) and request they call the patient's physician to inform that patient is going to respite care for 5 days and also to see if physician will see patient at the nursing home.

7. If needed, call the ambulance or Medicar.
  • Request specific time
  • Inform them about how many steps into the house and whether the patient is on the first or second floor
  • inform them if there is a need for oxygen
  • If using Medicar, order a wheelchair, if needed.
8. Call the family and confirm the time and destination.
9. Call facility Admissions Director and confirm time that patient will arrive.
10. Inform other hospice team members by voicemail.
11. Inform triage/communication line/hospice office.
12. Arrange return transportation after 5 days, if needed.

Tuesday, May 25, 2010

The Next Chapter

I am so excited to let you all know that I've been offered a pediatric social worker position!  My focus will be on children with brain tumors and sickle cell disease.  When I first decided to go into social work, I envisioned myself working with terminally ill children.  Then I landed in hospice and loved it.  The desire to work with children never quite went away.  I can't wait to be a part of the oncology and hematology departments and offer support to the children and families who require their services.  I am still marveling that God has brought me this far and that I will soon start my dream job!  I have a few weeks before I start work so I will be catching up on all my hospice/bereavement/end of life posts in the meantime. And once I've settled a bit into my new role, I plan to become a hospice volunteer because I could never fully leave end of life care.

Monday, May 24, 2010

Last Day

My last day of work was May 19.  I moved to Nashville the next day.  And now I'm unpacking and doing all the things one must do when they're settling in to a new place.  My last day of work was actually anticlimactic.  I saw my Bucket List patient and his wife one last time.  They gave me my favorite Irish Breakfast tea and we reminisced about all that was accomplished in the almost 2 years that I have been visiting them.  My employer still had not hired my replacement so I have been prepping all my patients that my caseload has been divided between the other 3 social workers and that they will likely not be seen on the same visit frequency because of this, unless there is an urgent need.  Most of my patients have been sad to lose me but excited by this new opportunity.  Of course, I worry about how some of my "favorites" will do without me but it's out of my hands.  At least the position has been posted and a couple of resumes have already been submitted.  Hopefully the remaining social workers will only be strained for a short time.

After visiting the patient, I headed to the office for an afternoon of meetings.  The psychosocial meeting was at noon and made me glad to be leaving because of some of the changes administration/Medicare wants to introduce.  Like charting on our laptops in front of patients.  Um, no thank you.  I can see how doctors or nurses might benefit from this but laptops are often perceived as barriers.  And if my job is to listen and be supportive, I don't want any barriers getting in the way of that!  True, some families might not mind or you might be able to sneak into a corner after the visiting is done to chart but it just doesn't seem right to me.

After that meeting, it was pretty well time for ICC.  A few of the nurses surprised me with goodies in honor of my last day.  Including a cookie cake with White Sox flags.  Do they love me or what?  In between discussing patients, I finished my charting, cleared my laptop, and gathered everything to be turned in.  And when the meeting was over, I hugged my coworkers goodbye amidst promises to keep in touch and then walked out the door.  I felt free.  I felt ready for the next chapter.  (Next chapter to be revealed soon!)

Sunday, May 16, 2010

Hair Matters

I've had really long hair for a couple of years.  Last week, I cut off a foot of hair for a sleek, new look (and donated the hair to Pantene's Beautiful Lengths program.)  It's been getting rave reviews and a few funny responses.  One of my coworkers told me I look so much more professional now.  Um, OK?  A patient took one look and said, "I liked it better long."  You can't please everyone!

Saturday, May 15, 2010

Nail spa?

What's something you wouldn't expect to happen on a routine visit?  I went to see a woman who had just celebrated her 95th birthday earlier this week.  She had received boatloads of flowers, cookies, and make-up as gifts.  She showed me her prettily painted pink fingernails and then asked me if I wanted some nail polish. I explained that I don't paint my fingernails because it chips off too easily- I don't like to make the effort.  Initially she accepted this reply but then she continued to ask me about doing my nails.  So finally I asked her if she wanted to do my nails.  She lit up like a Christmas tree!  She got out all the necessary tools, opened the nail polish, and then stopped.  "I can't see too good," she admitted.  I encouraged her that it was OK, we didn't have to paint my nails.  Well, she wouldn't have that.  She called her daughter over and directed her to do my nails.  The daughter and I were chuckling to ourselves because it clearly didn't matter to me if my nails were done or not...but since it mattered to this lady, I relented.  And so it was that a patient's daughter painted my nails in pink.

Thursday, May 13, 2010

Hand off

I went to see an patient with Alzheimer's and his daughter for the last time.  I've been visiting them since last summer, usually one or two times a month.  The patient can be combative at times, especially during personal care.  My hat is off to his daughter, not only for caring for this sometimes difficult man, but also because he abused her and her siblings when they were young.  Somehow she found the strength to forgive him and believes he deserves to be comfortable as he dies, in spite of the father he was. 

Whenever possible, I try to time my visits with the hospice RN.  I hold his hands while she changes the dressings on the wounds or changes the catheter.  For whatever reason, he stays calm when I'm holding his hands and listens to my words of reassurance as he's repositioned and tended to.  As I walked into his room this afternoon, he actually reached his hand out to me!  He's never done that before, although sometimes he seems to recognize me.  It was sweet to hold his hands one last time today.

Saturday, May 08, 2010


That's how many work days I have left!  I can hardly believe it.  Last night my Bucket List patient and his wife threw me a goodbye party.  I've admitted I don't have much by way of boundaries left with this couple.  I will certainly miss my weekly visits and helping "Jim" progress in his Bucket List.  He's knocked 20 + items off his list, with about 5 or 6 left to go.  The hospice RN has said she'll do her best to help him in my absence.  They haven't hired my replacement so I tried to pick an MSW that will be supportive for "Jan," as she relies heavily on me.  Jim and Jan are sad that I'm leaving but excited for the opportunities in Nashville.  Somehow I ended up cooking Pasta Carbonara for everyone- one last time in their kitchen.  The hospice team was there, as well as the former bereavement coordinator whom I adore, plus my parents.  And even though it was ostensibly in my honor, I felt like it was just a nice evening to gather together and eat good food.

Sunday night will be my last time on-call for hospice and I'm crossing my fingers the phone will stay quiet.  I probably just jinxed myself!  In the next 8 work days, I will try to see the remainder of my caseload that needs May visits (I think around 20 to go), plus wrap things up with 4 bereavement clients.  They aren't giving me any new patients anymore so that is a relief.  I can just focus on the people in front of me.  I also have to finish Stones into Schools for my Three Cups of Tea patient- just 40 pages to go.  We'll end with a tea party, as we did for the conclusion of Mortenson's first book.  The patient is less aware and sleeping more but every once in awhile she gives us an indication that she has been paying attention to the story.  I feel like it matters more to her husband that we finish reading the book but I'm interested to see how it ends too.  Beyond all this, I have to finish my charting, enter IDT notes one last time, and complete my exit interview and whatever else HR requires.  I think it's doable.  But I haven't factored in saying goodbye to my favorite patients or my coworkers.  It's best to stay in denial for now...

Sunday, May 02, 2010


Just two and a half weeks to go at work, only to be summoned for jury duty tomorrow.  While I'm normally all about civic duty, the timing could not be worse!  Oh well.  I'm hoping I'll get to sit there and read my book all day and then be dismissed.  Things are moving along at breakneck speed now.  The to-do list never seems to end.  I still need to set up my utilities and renters insurance, figure out banks, and buy all sorts of things for the new place.  Plus, divvying up what's mine vs. my roommate's in our apartment.  Plus, see all my patients one or two last times so that whichever MSW takes them over doesn't need to worry about May visits.  I had hoped that by giving 5 weeks notice, maybe just maybe they would hire someone to replace me before I left.  Wishful thinking, I know, but I even had a candidate in mind which I presented to my director before I gave notice.  Unfortunately, all kinds of changes are going down in the office and I think finding my replacement has gone to the bottom of their list.  I did my part to try to avoid screwing my coworkers over.  The May visits are the very least I can do now.

It's strange to be moving and not know where I'll be working.  My parents so did not raise me this way.  You always have a job lined up before you quit the job you have.  And yet, I am so glad to be taking this leap of faith.  If I had renewed my lease, then I would have missed out on interviewing for my dream job.  Even if I'm not offered the position, I feel like those interviews were a blessing from God and feel such assurance that something will work out. Truthfully, part of me is looking forward to a break.  I'll find out about the pediatric social work position after I move so I might not have much of a break before orientation starts.  (And I'm so excited about the position that I won't mind!) 

Coworkers and patients/families alike have been sad about my news but overall so excited for me.  Some people have talked about the roads they never traveled, and so maybe in some ways, they are living vicariously through my crazy adventure.  My Bucket List patient and his wife are so sad and keep telling me what a difference I've made in their lives.  His wife particularly seems lost- she relies so heavily on our weekly sessions.  On the other hand, they are my biggest cheerleaders and want to throw a little send off party for me.  The daughter of one of my favorite patients teasingly asked me how my move would affect my weekly visits.  And the patient himself asks me each week if I'm still planning on running off on him, then says he's going to keep telling me stories until I change my mind.  I'm trying to set up follow up for my bereavement kiddos and that seems to be falling into place. The bereavement coordinator asked me "Who's going to work with all our kids now?"  I had no answer for her- the program has largely been on hold, outside of what I'm able to accommodate, since she took over her role a year ago.  There are a couple of Just 4Kidz volunteers waiting in the wings though and I feel the program is in their good hands now.

I keep getting assigned new patients (hopefully I can put my foot down on that this week) and it is difficult to do my assessment and build rapport with them, only to tell them that I've resigned from my position and a new MSW will follow them after I leave.  Most of these families have been truly disappointed and I get where they're coming from.  It's hard enough for me to get to know them and know that I won't be able to see this through.  It seems unnecessarily cruel when patients and families have enough to deal with. 

On Friday I sat down after I finished my end of month charting and tried to divvy up my caseload.  Is it horrible to feel that with certain patients/families, no one else will be able to come close to me?  I'm not so naive or arrogant to think that no one can do as good a job as me...I just want my patients to have the best.  The other social workers are great but we all have such different styles that I worry/wonder how they will connect to some of the people I'll be giving them.  It's out of my hands though.