Case Manager/Social Worker (CM/SW) will make initial contact to Palliative Care (PC) regarding all hospice referrals.*
- Page #0500 for prompt response
- Evening and weekend referrals, call 263-1333 for data collection and follow-up as needed
PC will discuss with CM/SW and/or team to discern whether PC should meet with patient and family.
- If the patient resides in Dane County and their situation is straightforward, then a quick PC consult (by phone or in person) is sufficient to review and gather data to track referrals. Either CM/SW or PC will then refer patient to local hospice agency.
- The following situations are most appropriate for PC team to meet with patient/family:
- Any end-of-life (EOL) treatment decisions that are still being made (including dialysis, radiotherapy, chemotherapy, antibiotics, artificial nutrition and hydration)
- Symptom management needs (pain, nausea, dyspnea, agitation)
- Adjustment of acute care medication regimen to comfort care focus
- Patient/Family have questions about EOL issues or hospice services
- Patient resides outside Dane County
*When contacting, please provide:
- Patient name
- Reason (treatment decision, patient/family questions about hospice, symptom or medication management, etc.)
Several issues have led the Palliative Care team to propose greater involvement with hospice-related needs throughout the hospital. Some issues apply to all patients and others are specific to those served by HospiceCare Inc., our Dane County provider. We believe we are missing opportunities to improve our care of patients at the end of life. By reviewing all hospice referrals, and assisting where appropriate, we hope to ensure that all patients and families are optimally prepared when they choose hospice services.
One area of concern is staffing availability. At a time when Palliative Care has more staff available for consultations, HCI liaisons have been stretched more tightly. Some patients and families have been referred to HCI even though they are not in the agency's service area or have not yet decided to stop life-prolonging treatments — likely because of familiarity with HCI and their strong customer service approach. While HCI is happy to respond to all referrals, it is neither the best use of their time nor the most efficient way to address those patients' needs.
The other primary area for improvement is with smooth transitions. Through discussions with the HCI Intake team, we have discover that they would benefit from more consistency with discharge plans across all inpatient services. While some discharges require minimal work on their behalf, others require more time to secure orders that are appropriate for hospice care (especially medications and code status). The Palliative Care team is skilled at addressing hospice-related issues and can help teams to make the appropriate preparations for transition to either HCI or agencies outside Bane County.
We also hope that indirect benefits of this protocol will be to increase palliative care awareness throughout the hospital, serve a greater number of patients and families, and do a better job of tracking how we serve patients and families at the end of life.