Interview with Cherry Meier
Cherry Meier, MSN, serves as the Long Term Care Manager for the National Hospice and Palliative Care Organization. In that role, Ms. Meier provides strategic and operational leadership, management and resources for the advancement of hospice and palliative care services in the long-term care setting. She is the Chairperson of the Public Policy Committee of the Texas Hospice Organization, and worked for many years as a hospice nurse. Ms. Meier is the Director of Public Affairs for the VITAS Healthcare Corporation, and is licensed as a Nursing Home Administrator in Texas.
Q: Why is there a need for collaboration between hospice programs and long-term care facilities?
A: When the Hospice Medicare Benefit was first developed, the majority of caregiving was done at home. Since then there have been significant changes in our society-economically, many more older women need to be in the workplace; as medicine, technology, and pharmaceuticals have changed, more people are living longer with more chronic illnesses that makes staying at home more difficult. Also, families live farther apart, and communities that we used to be able to draw upon, like faith communities, are either shrinking or do not always have a younger population that can assist with caregiving at home.
Because of these reasons and others, more people are spending their last years in nursing homes or long-term care facilities, and therefore are dying there.
Q: What are some of the advantages of providing hospice care in these settings?
A: One of the biggest advantages is that it allows the hospice to provide additional end-of-life care training for the staff of these facilities. When these facilities were first developed, the focus was primarily on rehabilitation and cure, which was appropriate at that time. Now as patients are older, sicker, and dealing with more chronic illnesses, this focus needs to shift.
Hospice care can also be of great benefit to the patient, not just in terms of pain control and symptom management, but in helping to emphasize and support patient choice. When a patient in a long-term care facility elects to enter hospice care, he or she is certified by a physician as having a prognosis of six months or less and signs a consent form that shifts the focus of care from curative to palliative. These documents help to ensure that the patient's choices are valued, and carries over to the culture of the facility as a whole.
We've also seen that the involvement of the hospice interdisciplinary team can be very beneficial to supporting the work of the facility in general. The hospice team is skilled at documenting what is termed as "negative outcomes"-ie, decline and death-in a way that makes it clear that the patient did not suffer from abuse and neglect, but that the outcomes were due to the natural progression of the illness.
Studies have shown that a "spillover" effect often takes place when hospice is involved in long-term care settings, in that those patients not on hospice care often receive better pain management and symptom control, because of the role that hospice is playing in the facility.
Q: What are some of the barriers to collaboration between hospices and long-term care settings?
A: I have always believed that hospices and long-term care facilities could not be more in sync, in terms of their missions and philosophies towards older persons and end-of-life care. Many of the barriers are due to regulatory issues and liability issues. As we discussed above, the Hospice Benefit was not developed with long-term care settings in mind. Many long-term care facilities have a high staff turnover rate, and hospices have difficulty providing ongoing end-of-life education. Part of the barrier is in the public perception of long-term care-many of these facilities have worked hard to not be associated with dying and death (although, once again, this is certainly something that can be said to be a shared component with hospice programs.)
Q: An integral part of hospice care is bereavement support. What impact has this support had within these settings?
A: The support provided certainly has helped the families dealing with the death of their loved ones. Administrators and staff have learned a lot, too, about providing how bereavement impacts their work, and found ways like monthly memorial services to help deal with those issues. A significant population affected by grief in long-term care settings is the residents themselves. Not only do they grieve the loss of a fellow resident, that death often serves as an ongoing reminder of their own mortality. With their expertise in bereavement support, hospice professionals can help both the staff and the residents cope better with these feelings.
Q: In addition to the work of NHPCO, are there any other initiatives underway in this area?
A: The Center for Medicare and Medicaid Services (CMS) has developed the "Nursing Home Quality Initiative" project. The quality information is intended to be used by Medicare beneficiaries and their families to make placement decisions. This is an attempt to improve quality through consumer demand, rather than through increased regulatory oversight. Nursing Facility reports are due to be released to local newspapers in November of this year. Quality measures that were reported in a pilot project earlier this year in six states, have undergone refinement and the indicator for "weight loss" has been dropped. Some of the Quality Indicators are still somewhat controversial, but it is a step in the right direction. Information on nursing facilities in your area can be found at www.medicare.gov with a click on "Nursing Home Compare".
