How is VNA different from other hospice care providers?
VNA is a community-based, nonprofit hospice. We are one of the first hospices in the St. Louis area and not owned or operated by a hospital or corporate entity. We are nonsecular, and Joint Commission Accredited.
What does the referral process look like for physicians, case managers and other referral sources?
Referrals are received by the Hospice Director or hospice staff. It is ideal to call and discuss the goals of care for a referred patient. Once a referral is made, hospice will do the rest by contacting the patient or family member and setting up a home assessment to determine if the person is appropriate for care under Medicare guidelines. The primary care physician may assign the medical care to the hospice Medical Director or stay on as the patient’s physician.
How does VNA make sure the transition from palliative care into hospice is smooth?
Our Hospice and Advanced Illness Management (AIM) palliative care program are in the same office. Transfer of care is usually done in a face-to-face conversation between the palliative care team and the hospice team. Medical records are exchanged, and the goals of care are discussed and continued from palliative to hospice care. Hospice will sometimes meet at the patient’s home with the palliative care provider to include the family in the decision to transition.
What does the relationship with a patient’s physicians look like post-transition into hospice?
This is up to the physician. They can take a primary care role, a supportive care role or hand the care responsibilities to the Hospice Medical Director. If the Medical Director takes over care, all medications and medical supplies are ordered through them.
How does VNA communicate with a patient’s physician?
Some physicians have a close relationship with their patient and want to be fully involved in their care. Others see the benefit of a specially-trained doctor taking over care at the end of life. Hospice can work under any scenarios that the physician wants. Under Medicare regulations, the primary care physician (PCP) must order the hospice care services and if they want to stay as the primary care physician, must be available 24 hours a day by phone for medication management. The PCP must also certify the terminal illness of the patient every 90 days.
Palliative Care Referrals
How is VNA different from other palliative care providers?
VNA’s palliative care team is a physician-led, community-based palliative care program that sees patients at home through physicians and/or nurse practitioners.
What does the referral process look like for physicians, case managers or others referring to VNA’s palliative care?
The palliative care team needs an order for palliative care, demographics, last office visit note, or a discharge summary. The palliative care team will also need to know who in the family to reach out to in order to share more information about the Advanced Illness Management (AIM) palliative care program and to schedule the first visit.
If needed for the patient, how does VNA make sure the transition from palliative care into hospice is smooth?
VNA’s palliative care and hospice teams work very closely together to make a patient’s transition to hospice as easy as possible, communicating the patient’s needs, whether that be medical, spiritual, etc.
How does VNA’s AIM palliative care program work with physicians to communicate about the patient to keep them up to date?
The AIM team will call to collaborate with a patient’s physician when needed. Palliative care consult notes are sent to the primary care physician and relevant specialists after visits.