Nurse Delegation and Hospice Working Together with Long

Nurse Delegation and Hospice: Working Together with Long Term Care Workers Hospice October 2016 1

Nurse Delegation and Hospice ND PROGRAM MANAGERS - DSHS Erika Parada RN ND Program Manager Erika. parada@dshs. wa. gov 360 -725 -2450 Doris Barret RN Nursing Service Unit Manager barreda@dshs. wa. gov 360 -725 -2553 2

Nurse Delegation and Hospice Resources • Nurse Delegation Law RCW 18. 79. 260(3)(e) • Nurse Delegation Rules WAC 246 -840 -910 through 970 • Medication Assistance Rules WAC 246 -888 • Hospice Letter, NCQAC approved 1 -12 -2007 3

Nurse Delegation and Hospice Why ND and Hospice together can be a challenge 4

Nurse Delegation and Hospice Multiple nurses providing care Paid caregivers Community Settings 5

What is Nurse Delegation? “Registered Nurse Delegation” defined • Licensed registered nurse • Transfers the performance • Selected nursing tasks • Competent individuals • Selected situations WAC 246 -840 -920 6

How Does Nurse Delegation Work? • • • RN receives a referral for ND RN assesses a client, determines needs RN evaluates and teaches a LTCW performs a nursing task RN provides ongoing supervision and evaluation of task and client 7

Nurse Delegation and Hospice Critical Elements of ND • LTCW could not perform task outside of ND process • Client must be stable and predictable • RN must be notified of every change in client condition or treatment • All parties must be willing 8

Nurse Delegation and Hospice Criteria for ND • The client must be considered “stable and predictable” by the registered nurse delegator (RND). • The client must lack informal support to provide the delegated task. 9

Nurse Delegation and Hospice Criteria for ND • The client must be unable or unwilling to self-direct their care in the “in-home” setting. • All parties must be willing. 10

Nurse Delegation and Hospice • Who • What • Where • When 11

Nurse Delegation and Hospice Who 1. Registered Nurse 2. LTCW(NA-R, NA-C, HCA-C) 3. Client 12

Nurse Delegation and Hospice Long Term Care Workers Training • What kind of training does a LTCW need? § All LTCW must have ND (9 hr) class for NAs § When delegating to an NAR, he/she must have completed 40 hours CORE training 13

Nurse Delegation and Hospice When giving insulin, all LTCW must have completed ND: Special Focus on Diabetes, 3 hr class 14

Nurse Delegation and Hospice The Client § Stable and predictable § Consent to delegation process 15

Nurse Delegation and Hospice Stable and predictable means § Assessed by delegating nurse/makes the final call § Clinical and behavioral status is known § Does not require frequent evaluation by RN 16

Nurse Delegation and Hospice ? ? “Stable and predictable” ? ? for a hospice patient… q Hospice is specifically mentioned in the WAC • “Stable and predictable may include a terminally ill patient whose deteriorating condition is expected. ” WAC 246 -840 -930 (15) 17

Nurse Delegation and Hospice Tasks prohibited from delegation q. Injectable medications except insulin q. Sterile procedures q. Central IV line maintenance 18

Nurse Delegation and Hospice If not prohibited, delegating nurse may decide what task may be delegated § LTCW competency § RN’s experience and philosophy of practice § Agency policy 19

Nurse Delegation and Hospice Where • Private homes • Adult family home • All boarding homes • DDD certified programs 20

Nurse Delegation and Hospice • When • Specific task • Specific client • Specific caregiver 21

Nurse Delegation and Hospice Supervision for regular ND clients • Minimum of every 90 days • Could be more frequent for limited time Supervision for insulin-dependent clients • Once a week for the 1 st four weeks • More frequent is OK, short-term 22

What can LTCW do without ND? 1. Set up insulin devices = = loading the cartridge = placing needle on insulin pen = clicking a prescribed dose RCW 18. 79. 260(3)(e) 1. 23

Can a LTCW do anything without ND? 2. May not draw insulin into a syringe so client can self-inject. 3. LTCW may also verify the correct dose in a syringe for a sight-impaired client RCW 18. 79. 260(3)(e) 24

Nurse Delegation and Hospice WHEN DELEGATION MAY NOT BE NEEDED 1. 2. 3. 4. Personal Care Basic First Aid Self Directed Care Medication Assistance 25

Nurse Delegation and Hospice Tasks that don’t need delegation 1. Personal care 26

Nurse Delegation and Hospice • Basic first aid 27

Nurse Delegation and Hospice • Self-directed care • Only in private homes • Caregiver is an IP/not an agency worker • Client teaches and supervises RCW 74. 39. 050 28

Medication Assistance WAC 246 -888 -010 29

Medication Assistance Describes ways we can help an individual take their own medications ØMay be done by a lay person ØClient in community setting or their own home WAC 246 -888 -020 30

Medication Assistance Client must be q Able to get the medication where it needs to go § “must be able to put the medication into his or her mouth or apply or instill. ” q Aware that he/she is taking medication § “does not necessarily need to state the name of the medication, intended effects, side effects, or other details. . ” WAC 246 -888 -020 31

Medication Assistance To assist with legend drugs or controlled substances To assist with injectable medications ……. . EXCEPT prefilled syringes. May only hand to client, who must be able to self-inject. WAC 246 -888 -020 32

Medication Assistance Lay person may assist by ØOpening, pouring ØCrushing, dissolving ØReminding, coaching ØUsing an enabler ØMix with food or liquids 33

Medication Assistance If medication altered (= cut, crushed, mixed or dissolved) ◦ Practitioner determines safety to do so ◦ Documented on container or client record WAC 246 -888 -070 34

Medication Assistance ) What about oxygen? Requires a prescription; must be delegated unless client is independent in using it. What about nebulizers? Rules for medication assistance apply What about g-tubes? Rules for medication assistance apply WAC 246 -888 -090 35

Summary – Medication Assistance In certain situations, LTCW can “assist” client with taking their own medication Client must meet BOTH parameters in Medication Assistance WAC If client fits, LTCW can help in the ways described without nurse delegation 36

Nurse Delegation and Hospice • • Picture of Nurse Delegation Situations Where ND Not Necessary Medication Assistance Medicaid Clients/ Case Management 37

Nurse Delegation and Hospice Case Manager’s Responsibility: 1. Full social and needs assessment 2. In-person interview at least once a year, and when client has significant change 3. Work with the client and family to find acceptable caregivers Therefore, hospice should notify when client condition changes substantially. 38

Nurse Delegation and Hospice Case Manager’s Responsibility 4. Authorize payment for eligible services 5. In Medicaid, CM is the hub thru which all services flow 39

Nurse Delegation and Hospice Multiple nurses providing care Paid caregivers Community Settings 40

Nurse Delegation and Hospice Problems • Hospice may not do nurse delegation • Hospice nurses may not know ND is involved • RND may not know hospice is involved • RND may not be notified when hospice begins or orders change 41

Nurse Delegation and Hospice Issues • Comfort kits/E-kits • Limited dose of necessary meds • Symptom control when needed 42

Nurse Delegation and Hospice Reported Problems • RND has no verified physician orders • RND notified when E-kit arrives • RND not aware when client’s needs change 43

Nurse Delegation and Hospice Solution • Communicate, communicate 44

Nurse Delegation and Hospice • Standard of practice between ND and hospice • Nursing Commission approved 1/2007 WA State Hospice & Palliative Care Organization letter 12 -13 -06 • Needs wider circulation 45

Nurse Delegation and Hospice Principles/responsibilities • Hospice determines if ND is in place YES 1. Contact delegatin gnurse 2. Advise RND client elected Hospice 3. Inform RND how to reach Hospice 4. Advise RND when Ekit expected 5. Fax hospice orders to RND

Nurse Delegation and Hospice Principles/responsibilities Hospice determines if ND is in place NO 1. Contact client’s Medicaid case manager to initiate Nurse Delegation

Nurse Delegation and Hospice Principles/responsibilities Delegating nurse (when advised client has hospice) will delegate RND 1. Teach/delegate ordered meds and treatments to paid LTCW 2. Leave written instructions in the home 3. Supervise delegated LTCW and task response 48 by client

Nurse Delegation and Hospice Delineating Responsibilities Delegating nurse is the task teacher 49

Nurse Delegation and Hospice Delineating Responsibilities Hospice nurse is the symptom manager 50

Nurse Delegation and Hospice Therefore, when symptoms change, LTCW contact the hospice nurse 51

Nurse Delegation and Hospice If new meds or treatments are ordered, hospice should fax the orders to the delegating nurse 52

Nurse Delegation and Hospice RND teaches the LTCW and delegates the new meds or treatments to them, documents it in client’s chart 53

Nurse Delegation and Hospice If ND is initiated after hospice is already in place, RND contacts hospice to begin coordinating care. 54

Nurse Delegation and Hospice Good communication • Improves patient care • Fosters provider collaboration • Keeps client in least restrictive setting • Maintains autonomy • Promotes safe practice 55

Nurse Delegation and Hospice Everybody wins 56