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原文：

AModelforSuccessful

NursingHome–HospicePartnerships

SusanC.Miller,Ph.D.,M.B.A.

Abstract

Background:

Whilebenefitsofhospicecareinnursinghomeshavebeendocumented,interorganizationalchallengessuchasstaffconflictsregardingplannedcareortheirrespectiveroleshavealsobeendocumented.

Throughcasestudies,thisresearchaimedtocharacterizethepartnershipsofsuccessfulnursinghome–hospicecollaborators.

Methods:

Sixnursinghomesandhospiceswithself-identifiedsuccessfulcollaborationswerestudied.Interviewsofcareprovidersandchiefexecutiveandfinancialofficerscollectedinformationonpracticesrelatingtosevendomainsidentifiedascriticaltothecollaboration.Theorganizationalfactorsandactivitiesrelatingtoinfrastructuredevelopmentandcarecollaborationandprovisionmostcommonacrosssiteswereidentified.

Results:

Nursinghome–hospicecollaboratorswerephilosophicallyandotherwisealigned;

theyhadsimilarmissions,understoodtheirdifferingapproachestocare,andadministratorsdemonstratedanopennessandsupportforthecollaboration.Hospicesdevelopedinfrastructurestocorrespondtotheuniquenessandcomplexityofthenursinghomeenvironment.Forexample,theyhirednurseswithnursinghomebackgrounds,createdteamsdedicatedtonursinghomecare,andtrainedhospicestaffinproblemsolvingandconflictresolution.Carecollaborationprocessesfocusedontheimportanceoftwo-waycommunicationbyactivelysolicitingandsharinginformationwithnursinghomestaffandrespondingtonursinghomestaffandadministrators’concerns.

Conclusion:

Whilesuccessfulcollaboratorswereorganizationalaligned,hospiceleaders’acknowledgementthatpalliativecareprovisioninnursinghomesiscomplexanduniquewasimportanttosuccess.Accordingly,theprevalentpartnershipmodelwasaproductofstrategiceffortsbyleadersaimedatmatchingtheirstaffingtothenursinghomeenvironmentandpromotinggoodcommunicationandskillsneededforproblemsolving.

Introduction

Over25%ofAmericansdyingfromnotraumaticcausesspendthe‘‘finalchapter’’oftheirlivesinnursinghomes.1Increasingly,nursinghomeend-of-lifecareisprovidedtomorediverse,frail,andclinicallycomplexindividuals.Whileprovidinghigh-qualityend-of-lifecaretothesediverseindividualsischallengingfornursinghomes,thischallengeisintensifiedbythereimbursementandregulatoryenvironmentsinwhichU.S.nursinghomesoperate.Furthermore,thesecuringofpalliativecareexpertiseandsupportthroughpartnershipswithhospiceproviderscanaddtoexistingcomplexity,giventhechallengesknowntobeinherentwithinterorganizationalcollaborations.Perhapsbecauseofthis,22%ofU.S.nursinghomesin2004didnotpartnerwithhospices,andforthosethatdid,themagnitudeofhospiceusevariedwidelyacrossandwithinU.S.states.

In1982theU.S.CongresspassedlegislationallowingpaymentforhospicecaretoterminallyillMedicarebeneficiaries，andin1986thebenefitwasextendedtoterminallyillMedicarebeneficiariesresidinginnursinghomes.NursinghomescanofferMedicarehospicecarebydevelopingworkingrelationships（includingformalcontracts）withcertifiedMedicarehospiceproviders.Researchatteststohospice’spositiveimpactonthecareandoutcomesofnursinghomeresidentsenrolledinhospiceandsuggestshospicepresenceinnursinghomesresultsindiffusionofhospicephilosophyandpracticestothecareofresidentsdyingwithouthospice.

Whilehospicebenefitshavebeendocumented,interorganizationalcollaborationspresentchallengesthatcanaddtonursinghomeoperatingcosts（forexample,byincreasingmanagementtimeneededtoaddressconflicts）andarisefromfactorssuchaspoorlycoordinatedcareand=orstaffconflictsregardingplannedcare（e.g.,theuseofmorphine,other）andtheirrolesincareprovision.Additionally,regulatoryoversightpresentschallengessincesurveyorsmaycitenursinghomesfordeficienciesrelatedtohospiceapproachestocarethataredifferentfromwhatnursinghomeregulationsencourage（i.e.,palliativeapproachestocareversusrestorationorrehabilitation）.Furthermore,selectedstateMedicaidnursinghomereimbursementpoliciesandpracticesappeartopresentnursinghomeswithfinancialincentivestonotpartnerwithhospices.Forexample,somestatesmanually（versuselectronically）reviewnursinghomeMedicaidclaimsforresidentsenrolledinhospiceandthisresultsinslowerpayments.

Sincesuccessfulnursinghome-hospicecollaborationshavethepotentialtoleadto‘‘partnershipsynergy’’whereprovidersanddyingresidentsandtheirfamiliesbenefitfromthedifferingcareexpertiseandculturesofnursinghomeandhospiceproviders,effortstofacilitatesuccessfulcollaborationsareimportant.Withthisinmind,theresearchreportedhereaimedtounderstandtheorganizationalfactors=resourcesandactivitiescommontosuccessfulnursinghome–hospicecollaborators.Togainthisunderstanding,giventhecomplexityofpalliativeandnursinghomecareandofinterorganizationalpartnerships,casestudieswereconducted.Thegoalofthisresearchwastodocumentanddisseminatethepracticesofsuccessfulrolemodels（i.e.,positivedeviates）,whichproviderscouldthenemulatetoachievesimilarsuccesses.

Organizationfactorsandactivities

presentatstudysites

Organizationalfactors/resources.Bothnursinghomeandhospicechiefexecutiveofficers（CEOs）reportedtheirorganizationshadcommunity-focusedmissionsandtheyverbalizedsharedphilosophiesandgoalsofcare.Inparticular,nursinghomeCEOscitedtheirnursinghomes’recognitionoftheneedtosupportthespecialneedsofdyingnursinghomeresidentsandfamilies,andatbothsettings,staffspokeaboutthenursinghomeandhospicehavingacommongoal—thatofprovidingqualityend-of-lifeexperiencestoresidents=families.MosthospiceCEOshadmuchfamiliaritywithnursinghomecareandthechallengingregulatoryandreimbursementenvironmentsinwhichU.S.nursinghomesoperate,andseveralwereactivelyinvolvedwithnursinghomemembershiporganizations.

WhilecommitmenttothepartnershipwasvoicedbybothCEOs,thehospiceCEOappearedtobethedrivingforcebehindsuccess.Infact,twonursinghomesreportedtheircollaborationsimprovedsubstantiallywithachangeinhospiceleadership.

Theactivities—establishingtheinfrastructure.Hospicesplannedorganizationalandstaffinginfrastructurescapableofsupportingtheuniquenessofnursinghomesettings,suchasthehighprevalenceofdementia,theintenseregulatoryoversight,andthegenerallystressfulenvironments.Contributingtothisplanningandthushelpingtomoldthepartnership,nursinghomeCEOssharedtheirexpectationswithhospices.Forexample,oneCEOstatedshemadeitclearshewantedhospicetobeavailable24/7andeducationprovidedtoallshifts.

Thefourlargerstudyhospiceshaddedicatednursinghomecareteamswhowereconsistentlyassignedtothesamenursinghomes,promotingtheformationofstrongrelationships.Thetwosmallerhospices（inCaliforniaandNewJersey）withoutdedicatedteamsreportednosignificantnursinghome–hospicestaffissuesbutalsohadlong-standingnursinghomerelationships（20and14years,respectively）.Criticaltohospice’sinfrastructurewasthe‘‘right’’hospicerecruitmentand/orassignment.Also,almostallnursesonthededicatednursinghometeamshadnursinghomeworkexperience.Severalnursescommentedhowtheirnursinghomebackgroundshelpedthemtoempathizewithnursinghomestaffandtogagethelevelofenvironmentalstressorsonanyparticularday,andthustomodifytheirbehavioraccordingly.Forexample,onehospicenurseexplainedhowonhigh-stressdaysshemodifiedwhenandhowsheapproachednursinghomestaff.

Thepresenceofliaisonsalsoappearedcriticaltosuccess.Forhospices,thenursinghomeliaisonpositionwasformalizedwithitbeingfull-timeatthelargerhospices.Innursinghomes,however,nursesupervisorsordirectorsofnursingoftenassumedtheliaisonduties.Hospiceliaisonsinteractedwiththeirnursinghomecounterpartsandraisedandrespondedtoconcerns,addressingproblemsnotresolvedatthestafflevel.Hospiceliaisonsreportedtheneedattimestoreassignanurseoraidewhowasnotagoodfitataparticularnursinghome.

Theactivities—processesrelatingtoimportantcollaborativedomains.Staffviewedhigh-qualitycommunicationascriticaltobothmanagingthecollaborationandtoprovidingwell-coordinatedcare.Infact,staffmostfrequentlycited‘‘communication’’atalllevelsasthemostimportantfactorforpartnershipsuccess.Anexampleofacommonconsistentcommunicationpracticewashospicestaff’sapproachtothenursinghomevisit—staff‘‘checkedin’’withdisciplinecounterpartsuponarrival,askedforinputontheresident/family’sconditionandneeds,and‘‘touchedbase’’afterthevisittoreportfindings/other.Importantly,processeswereinplacetoacknowledgenursinghomestaffandtoensurerespectwasconveyed.

Nursinghomestaffreportedone-on-oneinformaleducationprovidedbyhospicestaffwasmostimportantinadvancingtheirpalliativecareknowledge,butalsovaluedtheformaleducationprovidedbyhospices（onaverage,twotofourprogramsperyear）.Mosthospicesprovidedtheirstaffwitheducationonrelationshipbuildingandonnursinghomesandtheirregulatoryenvironment.Hospicemedicaldirectorsattwohospiceswereparticularlyinvolvedinstaffeducationalefforts;

oneperformed‘‘rounds’’atnursinghomeswithnursinghomestaffinattendanceandanotherreportedempoweringhospicestaffbyhelping