Triage at End of Life: It’s not just for the ERBy Seasons | June 01, 2021
Triaging patients isn’t just something that happens at a hospital or during an emergency.
Having a plan and process for how to stratify the risks and care needs of patients extends even to those on hospice. Ensuring your hospice partner can capably triage has significant implications for you as a health system or value-based care provider as well: hospice patients with unmet needs are much more likely to dial 911, or visit an emergency room when experiencing an acute episode. Both of these scenarios could lead to unnecessary 90-day readmissions or futile and expensive treatments.
What should I expect from my hospice partner when it comes to triage?
Your hospice partner should have an active plan in place for anticipating patient needs and working to keep them safe and comfortable. Some key elements of an acuity/triage framework are:
- A Plan for After-Hours: The end of life process doesn’t just happen Monday through Friday between 9-5, and hospices are expected to support patient needs 24/7. While routine visits do happen in normal working hours, a hospice should be able to support patients on nights and weekends. Support services such as weekend on-call and a call center with EMR access are good signs that your hospice partner can handle the crises, big or small, that happen outside of working hours.
- A Matrix for Assessing Needs: While the dying process is unique for each individual, there are common signs and symptoms that a hospice patient may need more attention as their terminal illness runs its course. By assigning these patients into a high/medium/low framework, hospices can ensure that patient needs are met. Examples of anticipating patient needs might include (but are not limited to):
- Reporting pain above a self-identified threshold for comfort
- Are they a FULL CODE despite being on hospice?
- Unsafe living conditions
- Patients with changes in condition, even when expected
- Lack of caregiver support
- Established patients with well-managed symptoms
- Funeral arrangements in place
- DNR or MOLST in place
- Understanding and Responsibly using all Four Levels of Hospice Care: If your hospice provider doesn’t provide the four offered levels of hospice care (routine, respite, continuous, general inpatient) in eligible settings, that could be a point of concern. While not every patient will need all 4 levels during their hospice stay, there are valid and critical reasons for patients to utilize them as a part of their plan of care. A hospice provider that has the Medicare-required capacity and knowledge to provide all four levels can use them to manage patient needs and keep patients from readmitting to the hospital.
- An Acknowledgement that Triage in Hospice is much more than Physical Acuity: While good hospice care requires significant skills in pain management, wound care, and attending to physical needs such as bathing and grooming, there is an enormous psychosocial need that hospices must support. Patients facing the end of life can often:
- Experience a resurgence of PTSD or trauma from events earlier in their life, especially if they are veterans;
- Have questions of faith or spirituality;
- Have complex family dynamics including grief, or not being aligned with hospice goals of care for their loved ones;
- Be battling addictions;
- Not have their affairs or finances in order.
A hospice social work, music therapy, and chaplaincy team that continually assesses their patients for signs of these issues will help them to cope with grief and make the most of the time that they may have together. When patients and families have unmet emotional needs, it can exacerbate physical symptoms and lead to more expensive treatments for the patient.
If your health system or risk-based organization is looking for a hospice provider as a part of your strategy to lower costs or reduce rehospitalizations, asking questions about their triage strategy should be a consistent part of your review.