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

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

2. 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

3. 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

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

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

6. 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

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

8. 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

9. 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.

10. 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.

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

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

13. 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

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

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

16. 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

17. Nurse Delegation and Hospice ??“Stable and predictable” ?? for a hospice patient… • 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)

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

19. 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

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

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

22. 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 1st four weeks • More frequent is OK, short-term

23. What can LTCW do without ND? • Set up insulin devices = = loading the cartridge = placing needle on insulin pen = clicking a prescribed dose RCW 18.79.260(3)(e)

24. Can a LTCW do anything without ND? 2. May not draw insulin into a syringe so client can self-inject. • LTCW may also verify the correct dose in a syringe for a sight-impaired client RCW 18.79.260(3)(e)

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

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

27. Nurse Delegation and Hospice • Basic first aid

28. 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

29. Medication Assistance WAC WAC 246-888-010

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

31. Medication Assistance Client must be • 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.” • 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

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

33. Medication Assistance Lay person may assist by • Opening, pouring • Crushing, dissolving • Reminding, coaching • Using an enabler • Mix with food or liquids

34. 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

35. 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

36. 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

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

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

39. 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

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

41. 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

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

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

44. Nurse Delegation and Hospice Solution • Communicate, communicate, communicate

45. 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

46. Nurse Delegation and Hospice Principles/responsibilities • Hospice determines if ND is in place

47. Nurse Delegation and Hospice Principles/responsibilities Hospice determines if ND is in place

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

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

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