Better Conversations, Better Transitions: A Home Health Nurse's Take on Hospice

Speaker A: Welcome to the Voices of Hospice Leadership Podcast. Uh, the show that reveals how to take your hospice to the next level. We cover all things hospice, from marketing and automation to billing and operations. You'll also hear from professionals in the industry as they share their stories of success and practice growth tactics. Here is your host, Brian France.

Speaker B: Angie, welcome to the Voices of Hospice Leadership Podcast. Um, really excited to have you here and talk about your journey into hospice, the connection between home health and hospice, and how better conversations can lead to uh, better care. So please introduce yourself and tell us about your role with vivi.

Speaker A: I would love to, um, yeah, thank you for reaching out. This is um, really exciting to connect about. Um, my name is Angie Odry and I am a nurse by background and, and I am the director of hospice for Vivi, uh, Healthcare in the great state of Minnesota. Um, Vivi's actually in Minnesota, North Dakota and Wisconsin. But ah, the team I serve is in the Twin Cities metro area. Um, and that's a new area for us at VIVI where we are looking to grow. So I'm really excited to be here. Um, I am new to hospice, however, I have been working in the post acute home space for, for over 15 years. So it's been a transition for me going from that home health world into hospice. But uh, it's pretty exciting.

Speaker B: Awesome. So I know you do have a really interesting background coming into this role and I think that gives a unique perspective. You did spend many years in home health before moving into hospice. So what drew you to hospice and why did this feel like the right time to make that transition?

Speaker A: I always tease. I accidentally ended up in home health, um, when I worked at the hospital, ah, I was on a med surg floor and one of the populations that we served were adult cystic fibrosis patients. And if you know anything about adult cf, it gets pretty tricky and hairy at the end. And so they would be in and out of the hospital, um, really trying to get as well as they could. But ultimately it is, at least at that point it was something that would take their lives and so many of them would come back to the hospital. Um, they wanted access to staff all the time. And so we would have the patient, the families there with us for, you know, several days or even a week or so on end. And I kind of gravitated toward them. Um, I wanted to make that experience as a safe, as unscary and as beautiful as I possibly could. So I, I found that I really was drawn to those types of patients. So I decided that I wanted to do more of that. I wanted to, um, have those tough conversations where people were transitioning from, from curative treatment into end of life. And so I ended up in home health, um, where I, the, the company I worked for had a palliative care program m. That was part of, part of the home health space. So I ended up in home health. And so I worked in there as well, partnered with palliative care, and kind of supported that palliative care program for about 10 years. So as a result of that, we walked beside hospice for all of that. Um, and my career before I came to VIVI had gotten to a point where I was really far away from patients and the care, and I wanted to get back to it. And I realized the type of care I really wanted to get back or closer to was that end of life care. So this opportunity to come and support this team and kind of change paths presented itself, and I'm really grateful that I took it.

Speaker B: Awesome. Yeah. That background seems especially relevant because you've seen the patient journey before hospice, uh, begins. How has your home health background shaped the way you look at hospice differently than someone who started directly in hospice?

Speaker A: Well, I think what I realized, um, I remember I woke up one morning, I was like, man, there's so many patients that are in home health that should be in hospice. And I, I always knew this from the home health world. Um, but it just, it really dawned on me there. There's so many of them that are hidden away in home health. And, and what is, what is it that we can do? How can we help to grow the, that hospice census by looking at that home health population? Um, I also realized in this role how critically important it is for home health clinicians to be well versed, not only like in the hospice benefit, but also how to identify the patients and families who might be appropriate and would be well supported by hospice.

Speaker B: Yeah. One of the things you mentioned in our call that stood out was the, the connection between home health and hospice. And you said home health often has a significant hospice census within its current patient base.

Speaker A: Yeah, for sure.

Speaker B: What do you mean by that?

Speaker A: Well, I have found that many people, as they get closer to the end, um, they're really struggling with, with being emotionally ready. And so it feels safer to say, well, I'm going to go, I'm going to go to home health. It feels a lot safer. It's not quite as death and die as hospice. I'm going to, I'm going to try home health for a while. Um, I'M going to try a couple PT sessions and see if that helps. And so they will often land in the home health space because it's safer for them. It's probably easier to get them there because it's not involving conversations about death and dying, which are things that we're not necessarily good at. Um, so they feel like it's a safer choice than hospice. And it just kind of happens to be a natural progression. Um, in reality, if we had taken the time ahead of that to really sit down and explain kind of where they were in their healthcare journey and what that looked like and what the hospice benefit maybe could offer them, they may make a different choice if they truly had informed consent. Um, but often it's easier to not have those conversations. So people will end up in home health. And so. And they receive amazing care in home health. I mean, I can't speak highly enough about home health clinicians. They do a great job, but the patient has a different needs that maybe they aren't as well versed in. And so that's why hospices ultimately can be the better choice. But it's tricky to get there. And I think home health just feels safer for a little while.

Speaker B: That naturally leads to the question of timing. So many families come into hospice later than they could. Why do you think so many hospice appropriate patients are identified later than they should be?

Speaker A: Well, I think the reality of that is that the subject of death and dying is relatively taboo in this country. In a lot of countries, it's not just this one. But it's really hard to talk to somebody about the fact that they might be dying. It's really hard for us as humans to accept that we might be dying or that our loved one might be. So we're super uncomfortable talking about it. Um, I also find that physicians are reluctant to discuss this and to bring it up as an option because, first of all, they don't have a lot of time to sit down and talk to their patients. And so these conversations can take an incredible amount of time. But it could also feel for a physician like they have failed, like they haven't been able to cure somebody or make somebody better because that's been the focus of their job. Um, I also know med schools literally provide hours of education on end of life during that course. And so we are graduating physicians who don't know how to have conversations and don't really understand how it works. Um, families are also not really. They. They don't want to lose their loved one. They. They are scared to lose that person, they love them. And so they, they're not necessarily wanting to acknowledge the decline that they might be seeing because they don't want to give up hope. They don't want to, um, they don't want to, you know, let go of that particular patient. So, so patients get stuck in the middle. Um, they don't want to let their family down, they don't want to let their providers down. So they keep fighting and as a result, you know. But again, I think it's tough. Stems a lot from our attitudes as a country on death and dying and the fact that it's just not normal to consider it or think about it.

Speaker B: Mhm. And when that transition does happen, well, it uh, can make a huge difference for everyone.

Speaker A: Absolutely. I think especially if we have patients transitioning right. From home health into hospice. I think it's really, we have such opportunity to do it well. I believe that in a perfect world that home health admitting clinician would be already assessing for hospice and would be starting to lay some bricks and foundations like, oh, looks like you've really been struggling. How's it going? Really kind of start opening that door a little bit and peeking through. Um, I think if we had our clinicians starting those conversations sooner so that they weren't happening in an urgent emergent situation where somebody is really struggling and really having to make an on the spot decision, I think that helps set it up as well. Um, I've also seen some really beautiful, um, home health discharges happening at the same time as the hospice admission. Um, so that those people can come together and do that warm handoff and that home health team can manage up the hospice team and let the patient and family know that they're, they're in really great hands. I think there's such an important element to that allowing the home health team to kind of close the loop and finish that care and then safely hand them off. I think what I see happen unsmoothly if we're talking about smooth transitions. I think what I see happen a lot though is that home health patients end up in the hospital. So they, we transfer them into the hospital and then they come out with a whole different care team and there's no, no, uh, opportunity for the home health team to say goodbye or to really kind of support that and make sure the hospice team knows what they need to know so they can support the patient and family well.

Speaker B: M. For leaders listening who may oversee both service lines, I think this is where operations and communication really matter. So for agencies that offer both what, what should they be doing better to make those transitions happen sooner and more seamlessly?

Speaker A: I think if agencies offer both, um, I think it's really important to invest in those home health clinicians, um, making sure they have the resources they need to safely bring up hospice as a conversation, um, and to make sure they know how to have goals of care conversations. It is an investment. It takes time to train, it takes time to support them as they get comfortable with it. But it really can, it can really pay off in making sure our patients have the care they need. It can help improve outcomes for the agency. And so it's really, I think it's really scary, you know, for a home health clinician, when a patient looks at them and says, do you think I'm dying? It's a really scary place to be. And you only get one chance to answer that question. Um, and if the clinician isn't prepared, it can have detrimental results. It can not only, you know, create a riff in the relationship between those two, but it can also prevent hospice, you know, delay hospice admission or even prevent it altogether if the results, if it doesn't go well. Um, I also, I think there's opportunities too, for agencies to cross train, like their social workers or their home health aides. We had an admission this week. It, uh, was a home health patient that came to hospice. And the family absolutely loves their home health aide. And so their request was, can we keep him on the hospice side? And we said yes, because, I mean, first of all, I've had patients absolutely refuse to go to hospice because they would not go without their aid. I don't think we realize in this world how important that relationship between the aid and the patient is. But, um, who can we cross train? Who can be the common ground between that home health and hospice space? Um, look for those opportunities. And if you don't have your own home health, find partnerships, like find people, other home health agencies that you can partner with, offer to do training for their staff, offer to help them feel safe in these conversations, because it may very well, uh, help support that collaboration, even between different agencies.

Speaker B: It's brilliant. Yeah. I think a big part of that seems to come down to the conversations clinicians are having in the home. You focused on empowering home health nurses to have end of life conversations. Why are clinicians in the home in such a unique position to have those conversations?

Speaker A: I think that one of the more obvious answers is time. We have physician, um, encounters are measured in minutes, um, and that's not enough time to do this. And so when you are in a home care, uh, episode, you are in that home sometimes multiple times a week, week after week in that space, talking to them. So there's more time to. Not only. It doesn't have to be one big conversation. It can be little bits of conversation over time. Um, home health clinicians are also in that patient's most sacred space. It is a more comfortable environment to have that conversation than sitting, you know, in a hospital gown, on a, in a bed there or on a, on a table in the clinic. Um, the home health clinicians are not bringing some new treatment to the table. They're not the family saying, oh, my gosh, you can't give up. You've got to keep fighting. Um, they really are a safe haven in the storm. I, I will never forget this patient that I cared for. Um, uh, by the time they found the cancer, it was so advanced, they couldn't tell if the primary site was lung or liver. It was just everywhere. I don't think there was a part of her torso that did not have something growing. I walked in the first time I took care of her, and this room was full of these women, these strong, powerful lawyers, and all these really wonderful women who were there to support her. And they were, we are here. We're fighting with you. And, and I remember I would ask the questions of the assessment, and I would. I would ask, like, how's your pain been? And the patient would start to answer, and then the friends would jump in and they would all give their version. Well, she took the pain meds 14 times. You know, they were trying so hard and to take such great care of her. I started to notice over a few visits that my patients stopped trying to answer. She stopped trying to say anything because she knew they were going to answer for her. So I did what any good palliative care nurse would do. I kicked them all out of the room. And I said, I just need to talk to her for a couple minutes. And, um, she was facing away from the door. And. And so as they all got up to leave and they left the room, she started to cry. And she cried for a solid 10 minutes. She just let the tears fall, and I held her hand and I just sat next to her. I was that safe haven for her. I was not telling her she needed to fight. I was not telling her she needed to do something different. I was not encouraging her. I just simply was there in that space with her. And I think that is what home health can do, no matter what your discipline is. Whether you are giving them a bath or you are the nurse administering an IV medication. Be in that safe space. Be being that non judgmental, you know, I don't have any skin in this game. I just want the best for you. I think that's where it gets really, really interesting and where we have a lot of power.

Speaker B: I think sometimes those conversations begin in a very direct and emotional way. When a patient asks something direct like do you think I'm dying? How should a uh, clinician respond?

Speaker A: Well it can be a, ah, can be a patient or it can be a family member. They can both kind of come at you with those questions and like the first time you get it, it can be like super scary and, and you're just like uh, what, what? You know, and I, I think what I, what I encourage people to, to do is to simply stop whatever you're doing. If you're in the middle of an exercise program or you are doing wound care, stop. Just stop and look at them and say why are you asking me that today? Tell me more. There's something going on. Yeah, you need to ask what's going on and you need to find that. So I, I think, I think that's a uh, kind of the best way to handle that is just to ask that open ended question.

Speaker B: Yeah. Yeah, I really like that. Uh, uh, you shared that in our, in our prep call you that I think it creates, creates a space instead of, you know, shut. Shutting the conversation down. Yeah, you mentioned uh, so you mentioned like why are you asking that? Why are you asking that today? Why is this uh, why is that such a, a helpful spot to begin or helpful space?

Speaker A: Well for starters it, it buys the clinician a little bit of time if they are really caught off guard and surprised. They can, they can. It gives them a few minutes to think about it. And I think in any communication education I have heard over the course of my life, it always involves open ended questions. And that's what it is, it's an open ended question because you don't know why they're asking it. I mean it could be something as simple as they had a dream they were dying and they, they're like well I had this dream like what's going, you know, it could be something simple like that. It could be an increase in pain or other symptoms. Um, we find sometimes that patients don't fully report their pain because that means they could be getting sicker. And so sometimes they under report because they don't want it to seem like they're getting sicker. Or maybe it's not a symptom, it's just a feeling or somebody said something to them that made them think about it. So once you know why, you can really kind of start to support. Support their needs and m. So what is it? Do we need better pain control? Do we, do we, you know, do we. Are they, you know, do they want to talk about that? Do they understand what's happening? Do they need a deeper conversation with their physician about the trajectory of their disease? What does that look like? So I think it gives you a chance to pause, but it really does, with that open ended question, give you the chance to hear what they're thinking, um, in a way that maybe they obviously weren't just comfortable coming out and telling you what it was. They. They asked you this big question, so.

Speaker B: Yeah, of course. Yeah, I love that. What? Uh, not every conversation starts that directly, but sometimes there are more subtle signs. What are some of the subtle signs that tell you, you know, might be. It might be time to move into a care conversation or a goals conversation. Ah.

Speaker A: I mean, not to talk about the home health aides anymore, but I will, because they often pick up on it sooner than anybody. Um, it could be they don't get in the shower the same way they used to. They don't have the strength to do that. It could be something simple like that. And so the home health aide comes to you to change the care plan and. And you're like, oh, okay, yeah, sure, I'll just drop it down to this. And you're like, but why, why is that happening? Um, it could be they're not progressing with therapy. Um, they're not, they're not, you know, they're not moving along. It could be that they're refusing visits. They may be saying, no, I don't want you to come today. I don't feel like it could be things like that. Um, sometimes they're just more quiet or, or they get cranky in ways that they didn't before. Like they're, you know, they're giving kind of more terse answers than what you maybe remember from before. So that could be a sign that they're having more pain or other symptoms. M. Some we use, we use some AI software that actually kind of looks for some of the more subtle changes. Um, it can, it pulls the vital signs so it can start to look for those. It can look for hospitalizations, it can look for, um, you know, symptoms. It can really start to kind of pull those pieces together that maybe the human eye doesn't See, when we're in there every single day, um, so I think there's a lot of ways that we can find those little subtle signs that are coming at us.

Speaker B: It's great. And once you recognize that those signs, the next step is kind of knowing what to ask. What are some practical questions clinicians can, can ask to better understand what matters most to the patient?

Speaker A: I have found that if you have a conversation that doesn't start with us asking them, you know, how do you feel about dying? Or I think if we can start the conversation in a less hospice space, it can be more successful. I try to teach clinicians to really ask them, what do you understand about your disease? What do you understand about the prognosis of, and the trajectory of what's happening with your body? Like, what do you understand clinically? Um, and then based on that, what do you, you know, what is your doctor said about your prognosis? Like, what has your doctor said about how long you, um, would be able to, to continue on with this diagnosis? And, and sometimes if, if they don't really truly understand their, their disease, their diagnosis, um, that might be a question back to the doctor. Like, they don't understand that they are at end stage heart failure. You really need to have a conversation to help explain. You know, nurses can't give prognosis, but we can, we can encourage the doctor to have that conversation. Um, I remember also, I've encouraged patients, don't ask, don't ask the doctor how long you have to live. Ask them how long other people with a similar diagnosis and similar symptoms how long they have lived. Because that takes a little bit of the pressure off because doctors can't, they don't have a, they don't have a, you know, crystal ball. They can't see the future, but they, they know data, and they know what the data can show for people in a certain place. Um, and then once you have those questions answered, okay, so based on, on these things, like, what are your goals? What's important to you? Um, and kind of exploring that for a bit. And then once you know what those goals are, okay, how can I help you meet that? How can I help you get there? Is it. Do you need a social work, uh, consult to come in and help fill out advanced directives? Um, do you need me to call somebody, you know, to get you more information on what's happening? Um, do we need a hospice referral? You know, what does that look like? So considering that, you know, and what's important, I mean, it's interesting how there's an event that can often be an event that people really want to get to and, and how can we help support them and get into that too? So it's just, it, it's a, it's a, it's an, it's a conversation and I think it's a conversation we could use for everyone in chronic, with chronic illness to really explore. What do they know, what's important to them and what do they want, um, as they go along.

Speaker B: Yeah, really important skills. And I don't think they always come naturally.

Speaker A: No.

Speaker B: Teams need support and practice.

Speaker A: Right.

Speaker B: How do you help clinicians get more comfortable with these conversations?

Speaker A: I think, I think you can do it in a variety of ways. Um, you can have clinicians go like on a co visit with a, uh, experienced clinician so they can kind of see it happen. Um, and sometimes it's really helpful, like if it's their patient that they have a more experienced clinician that they could call to come in and visit with them and have a conversation. Um, sometimes you kind of even make appointments for the conversation. So bringing in the right people can be helpful. Um, I think role playing in a safe setting is really important. Um, having the opportunity to kind of pretend you're having this conversation. Um, but I think, as you know, I think we also need to make sure the clinicians really fully understand the benefit, um, of hospice and what that insurance benefit entails. Um, because, you know, sometimes, you know, we have to really kind of look at, have them, you know, what can we tell them about the benefit that, you know, that maybe is less scary than them hearing the H word and talking about hospice person.

Speaker B: So you mentioned role playing, which probably makes some people a little uncomfortable, but

Speaker A: it's not the favorite. No.

Speaker B: Sounds important.

Speaker A: Yeah.

Speaker B: Um, what, why do you think role playing matters so much? Especially in conversations where you may only get, you know, one chance to do it well.

Speaker A: Right. I think it's like any other new skill. Um, the first time you, you know, maybe go bowling, it feels really awkward and you've got to figure out, and how do I hold this ball? And you know, and not to mention it, it feels awkward. But then you've got all this nervous energy like, oh my gosh, I haven't done this before, what if I screw this up? I'm going to scar them for fore know. Um, but so that's why I think it's really important. What we used to do is we would break up into small groups of three or four and one per, one person would be the Nurse. One person would be the patient, and one would be like either a spouse or a child. Right. And so, um, we would then present a scenario, and they had to kind of talk through the scenario. And there were. I usually gave them three scenarios because they all took turns. Because I said, if you're going to be the really annoying daughter, well, then you're. She's going to get the chance to be the annoying daughter for you. So, um, but I think, think, you know, in those smaller. Those smaller groups are a little less scary for people, you know, versus sitting down in a big room and talking through it. Um, but I think those, you know, outside of role playing, again, I think having those opportunities to shadow or to go along or have somebody go along with you can be really important.

Speaker B: Love that. I think another challenge is that even when the conversation is handled well, families often bring a, uh, lot of misunderstanding about hospice into it. What. What are some of the biggest misconceptions patients and families still. Still have about hospice?

Speaker A: I'll never forget my little lady. I had a. I had talked. Talked everything through. She's like, okay, this sounds great. And she goes, I'm ready to go to hospice. And I said, perfect. She started getting up. I'm like, where are you going? She goes, well, I'm going to pack my bag. And I'm like, you're not going anywhere. So I think people think it's a place that you go. And granted, there are residential hospices, and they're beautiful places, but for most people, hospices, wherever they are living and wherever they're calling home, um, so they think they have to leave their home. Um, they think they won't. I know another fear I've heard is that, well, if I fall and break my hip, I'm not going to get any treatment. Um, you will get some treatment. Nobody's going to just leave you there in pain. And so whether that is actually, you know, some sort of surgery or we can manage the pain with. With a different medication regimen, whatever that might look like. Um, but they think that, you know, if that happens or, you know, or if they have pneumonia and they get a uti, we're going to let them die of that. And that's just not the case. Right. Um, I think they also feel like they're going to die right away. Like maybe they're dying tomorrow if. If they go into hospice. And. And the reality is, data shows us people live longer enough hospice. So I think that's something that. That I think people are really surprised to hear about. Um, they don't realize they can revoke that once you. Once you, you know, elect hospice, you can revoke at any time if that's what you want to do. Um, and I just. I don't think they realize that it's an insurance benefit that they have paid into their whole lives. It's part of Medicare. Just like we pay taxes for the. For our Medicare coverage, hospice is that. And when we don't, you know, take advantage of that, that's. That's a whole benefit that we're leaving on the table.

Speaker B: Yeah, he talked about hospice as a Medicare benefit that people have, uh, paid into. And, you know, why does that framing help people understand hospice differently?

Speaker A: I think, um, I think if you start with talking about what the benefit offers, like, don't say the H word for a little while, like, hold on to that. Um, but talking about, like, the DME and the medication coverage, like, what that looks like. Um, I've had people just. The family getting out to get the medications all the time. I mean, just having those medications delivered was. Was a huge, you know, a huge thing for them. The spiritual care, um, the hospice aids, the, you know, the. The veteran programs, all the different components, and really talking about what that looks like, um, and making sure they know that this is a benefit that's designed to support you in your final months of life. Um, it's something that has been carved out by Medicare for you and ops. It's called hospice. Um, I think ears tend to close when you say the H word. Um, so that's why I like to say it at the end so that they, um, they can actually hear what it's about before they. Before their ears shut.

Speaker B: Love that. Uh, yeah, it seems like once families understand it better, many of them look back and. And wish, yeah, they had that conversation sooner. Have you found that families more often say, like, we wish we had started sooner rather than we started too early?

Speaker A: I've never had a patient say, man, I wish I hadn't been in hospice so soon. I've never in my life heard that. Um, but I cannot count the number of times when somebody has said, I really wish I had known about this sooner. I wish I had known what this was and how it could support me sooner. Um, I've heard that so many times. And that's why it's important that we. We move this work upstream the best that we can.

Speaker B: Love it. You also mentioned that technology, uh, started, uh, or is starting to play a role in helping teams identify patients earlier. What exactly can the software the data or the AI help clinicians recognize, uh, hospice eligibility sooner.

Speaker A: Clinician assessment. I want to make sure this is clear. Clinician assessment is absolutely vital. It is of the utmost importance. But when you see a patient multiple times a week for weeks on end, um, you, you can miss out on those subtle changes. It's just like a family member. You don't necessarily notice what's happening until, you know, until later on. And so the data is there. It can pick up, um, that's what it can pick up, like subtle changes in vital signs or drops over time. I mean, we're going to notice somebody's blood pressure drops off in one visit. We may not notice it over time or increases or their weight decreases. We may not be able to see that. Um, it is definitely not a replacement for the assessment of humans. But I think it's a great tool to help us open our eyes to somebody and at least ask the questions. Maybe somebody we wouldn't even have considered. Um, we have a wonderful team member who emails, who runs the reports and sends out every week to the clinicians, will send out, hey, these are the. That flagged through AI. What do you think? Like, what's going on with them? And, and so I think it's really been a helpful tool to help identify people a little bit sooner than we would maybe see to the naked eye.

Speaker B: Yeah, I think the people, people closest to the patient, you know, can miss that, that gradual decline, uh, simply because they, they seem so often.

Speaker A: Absolutely.

Speaker B: What, what can data pick up that, uh, even a, a good clinician might miss when, when they are seeing someone several times a week? I think you just mentioned, like, weight.

Speaker A: Yep. Weight, um, vitals. Uh, hospitalizations are huge. I mean, I think we, the amount of hospitalizations that people experience in the last, you know, year and months of life, it's really a huge indicator, um, therapy declines. You can start to see maybe therapies, subtle changes that are happening. Or it could be. Or it could be a combination of the diagnosis. Maybe there's another diagnosis that came along. Um, and that when you pull it all together, um, it kind of has triggers that it will, it'll, it'll grab and, and it's, it's just kind of all lives there in the data. So it's pretty cool.

Speaker B: One of the unique things about VIVI that you, uh, that you shared is that you operate across senior living, home health, and hospice. How does that create better continuity and better timing for hospice support?

Speaker A: I think that was one of the most exciting aspects of RIVY for Me was like, hey, we really have the whole package here. Um, we can support them in the ALS and the SNFs and really make sure they have the right level of care. Um, and I think it truly comes down to collaboration and communication. Um, if an ALS of an AL nurse or somebody in one of our buildings needs something, they just have to send a teams message to the person on the team. You know, hey, Bob's not looking good today. Come look at him. You know, whatever that might be. It's a quick teams message. Um, we also can document in the EMR what we're seeing and what we're doing in the home, which I think is really helpful. Um, we've actually done a lot of work here in the Metro, digging in even since I got here to figure out, what do you guys need? What would be helpful? What would help improve this collaboration and coordination? And it's something as simple as having access to the emr, but also being able to. With our badges, being able to swipe in, because we're all vivi. Being able to swipe in when they're up in a patient's room at 2am and they've called for symptom support, we can get ourselves in. It's even something as simple as that. Um, you know, it just. And being able to partner. We. I, uh, was in a building this week, and they were saying, you know, we really want to do more with veterans. And I'm like, well, we're a level four. We are veterans. Like, let's talk about this. How can we support you? How can we. How can we do that? Collaboration? Because. Because we're all vivi. So it's good.

Speaker B: Love that. And since hospice is newer for VIVI in the. In the Minneapolis area, you're helping build something meaningful. There's.

Speaker A: Yeah.

Speaker B: What excites you about helping grow hospice, uh, in the area within that model?

Speaker A: Well, it's my home, um, and as my family members progress, I mean, it's great to be able to know that the support is here, but there's so many things that I think are exciting. Um, VIVI is a merger between two pretty large agencies in the state of Minnesota. Knut Nelson was the home health and hospice, and Walker was the, um. In the. In the metro area had more of the buildings. And so having those two forces come together. Um, so, yeah, so the metro area did not have Knuth Nelson was not. They were more outstate Minnesota. So with this merger, we've come in here and it just. There's such opportunity here. There's so many people who truly need great care. And so it's been really exciting to kind of watch those service lines come together and, and we, you know, we have, we do work within population health and being able to really drive that and support people for the long haul. Um, and we can do it wherever they call home, you know, and that's been the beauty of it. But it's really truly. I think it comes down to seamless care, making sure the patients and the families have what they need. If you have families that aren't living with them, they know there's somebody there, whether, you know, no matter who it is from our team. So I think that's what's so exciting. Um, but yeah, it's really, it's amazing to have access to all of that and to be able to support and serve patients and families.

Speaker B: Love it. So we start to wrap up, Um, I want to bring it back to the. Maybe the leaders and the, uh, clinicians listening. For hospice leaders listening, what is one thing they should do differently to improve transitions into hospice?

Speaker A: Don't overlook your home health team as a referral source. They are a huge referral source for you. They are just as if not more important than the hospital discharge planners, the clinics and the assisted livings and the different buildings. They are a very important referral source. Um, and if you have a home health team or you have a partnership, invest in those clinicians. Make sure they have the resources they need. Make sure they have a good document that they can look at clinical indicators or what the hospice benefit is. Invest in them because it will come back. It will come back to you and it will help grow your hospice.

Speaker B: Awesome. And on the front lines, it often starts with one good question. So for clinicians listening, what's one good question that, ah, they can start asking today that opens better conversations with patients and families.

Speaker A: I always think about Atul Gawande's book. And there's a section in there where he talks about when you are talking, when you're working with a patient, you need to find out what baseline, what level do they need to be able to get back to. To want to continue living. And so I always think about my dad and my dad, if he could not eat ice cream and like watch television, he would not want to. I don't think he'd want to be here. And I. So I think it's important that, that we're. We're asking that and we're identifying that and if we could just ask them what's important to you what is most important to you right now in your life and in your world? And I think. I think that whether you have somebody who's, you know, moving toward hospice or not, I think it's important that we ask our patients what is most important to you? What matters to you most now?

Speaker B: Yeah. Angie, thank you again for joining today. I really appreciate it.

Speaker A: My pleasure.

Speaker B: Really appreciate your perspective and the experience you shared with us. Thank you.

Speaker A: Thank you so much. Oh, my pleasure. Be well,

Speaker B: Angie. Welcome to the Voices of Hospice Leadership podcast. Um, really excited to have you here and talk about your journey into hospice, the connection between home health and hospice, and how better conversations can lead to, uh, better care. So please introduce yourself and tell us about your role with vivi.

Speaker A: I would love to. Um, yeah. Thank you for reaching out. This is, um, really exciting to connect about. Uh, my name is Angie Odry, and I am a nurse by background, and I am, um, the director of hospice for vivi, uh, healthcare in the great state of Minnesota. Um, vivi's actually in Minnesota, North Dakota, and Wisconsin. But, uh, the team I serve is in the Twin Cities metro area. Um, and that's a new area for us at vivi, where we are looking to grow. So I'm really excited to be here. Um, I am new to hospice, however, I have been working in the post acute home space for over 15 years. So it's. It's been a transition for me going from that home health world into hospice. But, uh, it's pretty exciting.

Speaker B: Awesome. So I know you do have a really interesting background coming into this role, and I think that gives a unique perspective. Uh, you did spend many years in home health before moving into hospice. So what drew you to hospice and why did this feel like the right time to make that transition?

Speaker A: I always tease. I accidentally ended up in home health. Um, when I worked at the hospital, I was on a med surg floor. And one of the populations that we served were adult cystic fibrosis patients. And if you know anything about adult cf, it gets pretty tricky and hairy at the end. And so they would be in and out of the hospital, um, really trying to get as well as they could. But ultimately it is, at least at that point, it was something that would take their lives. And so many of them would come back to the hospital. Um, they wanted access to the staff all the time. And so we would have the patient, the families there with us for several days or even a week or so on end. And I kind of gravitated toward them. I wanted to make that Experience as a safe, as unscary, and as beautiful as I possibly could. So I. I found that I really was drawn to those types of patients. So I decided that I wanted to do more of that. I wanted to, um, have those tough conversations where people were transitioning from. From curative treatment into end of life. And so I ended up in home health, um, where I. The company I worked for, had a palliative care program that was part of the home health space. So I ended up in home health. And so I worked in there as well, partnered with palliative care, and kind of supported that palliative care program for about 10 years. So as a result of that, we walked beside hospice for all of that. Um, and my career before I came to VIVI had gotten to a point where I was really far away from patients and the care, and I wanted to get back to it. And I realized the type of care I really wanted to get back or closer to was, was that end of life care. So this opportunity to come and support this team and kind of change paths presented itself, and I'm really grateful that I took it.

Speaker B: Yeah, that background seems especially relevant because you've seen the patient journey before hospice begins. Yeah. How, uh, has your home health background shaped the way you look at hospice differently than someone who started directly in hospice?

Speaker A: Well, I think what I realized, um, I remember I woke up one morning, I was like, man, there's so many patients that are in home health that should be in hospice. And I. I always knew this from the home health world. Um, but it just. It really dawned on me there. There's so many of them that are hidden away in home health. And, and what is. What is it that we can do? How can we help to grow that hospice census by looking at that home health population? Um, I also realized in this role how critically important it is for home health clinicians to be well versed, not only, like, in the hospice benefit, but also how to identify the patients and families who might be appropriate and would be well supported by hospice.

Speaker B: Yeah. Um, one of the things you mentioned in our call that stood out was the. The connection between home health and hospice. And you said home health often has a significant hospice census within its current patient base.

Speaker A: Yeah, for sure.

Speaker B: What do you mean by that?

Speaker A: Well, I have found that many people, as they get closer to the end, um, they're really struggling with. With being emotionally ready. And so it feels safer to say, well, I'm gonna go. I'm gonna go to home health. It feels a lot safer. It's not quite as death and die as, as hospice. I'm gonna, I'm gonna try home health for a while. I'm gonna um, I'm gonna try a couple PT sessions and see if that helps. And so they will often land in the home health space because it's safer for them. It's probably easier to get them there because it's not involving conversations about death and dying, which are things that we're not necessarily good at. Um, so they feel like it's a safer choice than hospice and it just kind of happens to be a natural progression. Um, in reality, if we had taken the time ahead of that to really sit down and explain kind of where they were in their healthcare journey and what that looked like and what the hospice benefit maybe could offer them, they may make a different choice if they truly had informed consent. Um, but often it's easier to not have those conversations. So people will end up in home health. And so, and they, they receive amazing care in home health. I mean, I, I can't speak highly enough about home health clinicians. They do a great job, but the patient has a different need set that maybe they aren't as worse as well versed in. And so that's why hospices ultimately can be the better choice. But it's, it's tricky to get there. And I think home health just feels safer for a little while. Mhm.

Speaker B: Yeah. That naturally leads to the question of timing. So many families come into hospice later than they could. Why do you think so many hospice appropriate patients are identified later than they should be?

Speaker A: Well, I think the reality of that is that the subject of death and dying is relatively taboo in this country. And uh, well, in a lot of countries it's not just this one. But it's really hard to talk to somebody about the fact that they might be dying. Really hard for us as humans to accept that we might be dying or that our loved one might be. So we're super uncomfortable talking about it. Um, I also find that physicians are reluctant to discuss this and to bring it up as an option because first of all, they don't have a lot of time to sit down and talk to their patients. And so these conversations can take an incredible amount of time. But it can also feel for a physician like they have failed. Like they haven't been able to cure somebody or make somebody better because that's been the focus of their job. Um, I also know that, you know, med schools literally provide hours of education on end of life during, during that course. And so we are, we are graduating physicians who don't know how to have conversations and don't really understand how it works. Um, families are also not really. They, they don't want to lose their loved one. They, they are scared to lose that person. They love them. And so they, they're not necessarily wanting to acknowledge the decline that they might be seeing because they don't want, they don't want to, um, they don't want to, you know, let go of that particular patient. So, so patients get stuck in the middle. Um, they don't want to let their family down, they don't want to let their providers down. So they keep fighting and as a result, you know. But again, I think it stems a lot from our attitudes as a country on death and dying and, and the fact that it's just not normal to consider it or think about it.

Speaker B: Mhm. And when, um, that transition does happen, well, it uh, can make a huge difference for everyone.

Speaker A: Absolutely. I think especially if we have patients transitioning right from home health into hospice. I think it's really, we have such opportunity to do it well. Um, I believe that in a perfect world that home health admitting clinician would be already assessing for hospice hospice and would be starting to lay like some bricks and foundations like, oh, you know, looks like you've really been struggling. How's it going? You know, really kind of start opening that door a little bit and peeking through. Um, I think if we had our clinicians starting those conversations sooner so that they weren't happening in an urgent emergent situation where somebody is really struggling and really having to make an on the spot decision, I think that helps set it up as well. Um, I've also seen some really beautiful, um, home health discharges happening at the same time as the hospice admission. Um, so that those people can come together and do that warm handoff and that home health team can manage up the hospice team and let the patient and family know that they're in really great hands. I think there's such an important element to that, allowing the home health team to kind of close the loop and finish that care and then safely hand them off. I think what I see happen unsmoothly, if we're talking about smooth transitions. I think what I see happen a lot though is that home health patients end up in the hospital. So we transfer them into the hospital and then they come out with a whole different care team and there's no opportunity for the home health team to say goodbye or to really kind of support that and make sure the Hospice team knows what they need to know so they can support the patient and family.

Speaker B: Well, m. For leaders listening who may oversee both service lines, I, uh, think this is where operations and communication really matter. So for agencies that offer both, what should they be doing better to make those transitions happen sooner and more seamlessly?

Speaker A: I think if agencies offer both, um, I think it's really important to invest in those home health clinicians, um, making sure they have the resources they need to safely bring up hospice as a. As a conversation, um, and to make sure they know how to have goals of care conversations. It is an investment. It takes time to train. It takes time to support them as they get comfortable with it. But it really can. It can really pay off in making sure our patients have the care they need. It can help improve outcomes for the agency. And so it's really. I think it's really scary for a home health clinician when a patient looks at them and says, do you think I'm dying? It's a really scary place to be. And you only get one chance to answer that question. Um, and if the clinician isn't prepared, it can have detrimental results. It can not only, you know, create a riff in the relationship between those two, but it can also prevent hospice. You know, delay hospice admission or even prevent it altogether if the results, if it doesn't go well. Um, I also, I think there's opportunities too, for agencies to cross train, like their social workers or their home health aides. We had an admission this week. It, uh, was a home health patient that came to hospice. And the family absolutely loves their home health, their home health aide. And so the request was, can we keep him on the hospice side? And we said yes, because, I mean, first of all, I've had patients absolutely refuse to go to hospice because they would. They would not go without their aid. I don't think we realize in this world how important that relationship between the aid and the patient is. But, um, who can we cross train? Who can be the common ground between that home health and hospice space? Um, look for those opportunities. And if you don't have your own home health, find partnerships like find people, other home health agencies that you can partner with, offer to do training for their staff, offer to help them feel safe in these conversations, because it may very well help support that collaboration, even between different agencies.

Speaker B: It's brilliant. Yeah. I think a big part of that seems to come down to the conversations clinicians are having in the home. For sure, you focused on empowering home health nurses to have end of Life conversations. Why are clinicians in the home in such a unique position to have those conversations?

Speaker A: I think that one of the more obvious answers is time. We have, um, physician encounters are measured in minutes. Um, and that's not enough time to do this. And so when you are in a home care, uh, episode, you are in that home sometimes multiple times a week, week after week in that space, talking to them. So there's more time to, to not only. It doesn't have to be one big conversation, it can be little bits of conversation over time. Um, home health clinicians are also in that patient's most sacred space. It is a more comfortable environment to have that conversation than sitting, you know, in a hospital gown, on a, in a bed there or on a table in the clinic. Um, the home health clinicians are not bringing some new treatment to the table. They're not the family saying, oh, my gosh, you can't give up. You've got to keep fighting. Um, they really are a safe haven in the storm. I will never forget this patient that I cared for. Um, uh, she had. By the time they found the cancer, it was so advanced, they couldn't tell if the primary site was lung or liver. It was just, just everywhere. I don't think there was a part of her, of her torso that did not have something growing. And I walked in the first time I took care of her, and this room was full of these women, these strong, powerful lawyers, and all these really wonderful women who were there to support her. And they were, we are here. We're fighting with you. And I remember I would ask the questions of the assessment, and I would, I would ask, like, how's your pain then? And the patient would start to answer, and then the friends would jump in and they would all give their version. Well, she took the pain meds 14 times. You know, they were trying so hard and to take such great care of her. I started to notice over a few visits that my patient stopped trying to answer. She stopped trying to say anything because she knew they were going to answer for her. So I did what any good palliative care nurse would do. I kicked them all out of the room. And I said, I just need to talk to her for a couple minutes. Minutes. And, um, she was facing away from the door. And. And so as they all got up to leave and they left the room, she started to cry. Um, and she cried for a solid 10 minutes. She just let the tears fall. And I held her hand and I just sat next to her. I was that safe haven for her. I was not telling her she needed to fight. I was not telling her she needed to do something different. I was not encouraging her. I just simply was there. And that's space with her. And I think that is what home health can do. No matter what your discipline is, whether you are giving them a bath or you are the nurse administering an IV medication, being that safe space, being that non judgmental, you know, I don't have any skin in this game. I just want the best for you. I think that's where it gets really, um, really interesting and where we have a lot of power.

Speaker B: Awesome. I think sometimes those conversations begin in a very direct and emotional way. When a patient asks something direct like do you think I'm dying? Uh, how should a clinician respond?

Speaker A: Well, it can be a, can be a patient or it can be a family member. They can both kind of come at you with those questions and like the first time you get it, it can be like super scary and you're just like, uh, what, what? You know, and I think what I, what I encourage people to, to do is to simply stop whatever you're doing. If you're in the middle of an exercise program or you are doing wound care, stop. Just stop and look at them and say, why are you asking me that today? Tell me more. There's something going on. Yeah, you need to ask what's going on and you need to find that. So I, I think, I think that's a, uh, kind of the best way to handle that is just to ask that open ended question. Question.

Speaker B: Yeah. Uh, yeah, I really like that, uh, you shared that in our, in our prep call. Ah, I think it creates, creates a, a space instead of, you know, shut, shutting the conversation down. Yeah, you mentioned, uh, so you mentioned like why are you asking that? Why you asking that today? Why is this um, why is that such a, a helpful spot to begin or helpful space?

Speaker A: Well, for starters, it buys the clinician a little bit of time. So if they are really caught off guard and surprised, they can, they can. It gives them a few minutes to think about it. And, and I think in any communication education I have heard over the course of my life, it always involves open ended questions. And that's what it is. It's an open ended question because you don't know why they're asking it. I mean it could be something as simple as they had a dream they were dying and they, they're like, I had this dream, like what's going. You know, it could be something simple like that. It could be an increase in, in pain or other symptoms. Um, we find sometimes that patients don't fully report their pain because that means they could be getting sicker. And so sometimes they, they, they under report because they don't want it to seem like they, they're getting sicker. So, or maybe, you know, maybe it's not a symptom, it's just a feeling or somebody said something to them that made them think about it. So once you know why, you can really kind of start to support their needs. And so, so what is it? Do we need better pain control? Do we, do we, you know, do we, are they, you know, do they want to talk about that? Do they understand what's happening? Do they need a deeper conversation with their families physician about the, the trajectory of their disease? What does that look like? So I think it gives you a chance to pause, but it really does with that open ended question, give you the chance to hear what they're thinking. Um, in a way that maybe they obviously weren't just comfortable coming out and telling you what it was. They, they asked you this big question, so.

Speaker B: Yeah, of course. Yeah, I love that. What? Uh, not every conversation starts that directly. What? Uh, sometimes there are more subtle signs.

Speaker A: Mhm.

Speaker B: What are some of the subtle signs that tell you, you know, might be, might be it might be time to move into, you know, a care conversation or goals. Uh, conversation.

Speaker A: I mean, not to talk about the home health aids anymore, but I will because they often pick up on it sooner than anybody. Um, it could be they don't get in the shower the same way they used to. They don't have the strength to do that. It could be something simple like that. And, and so the home health aid comes to you to change the care plan and, and you're like, oh, okay, yeah, sure, I'll just drop it down to this. And you're like, but why is that happening? Um, it could be they're not progressing with therapy. Um, they're not, they're not, you know, they're not moving along. It could be that they're refusing visits. They may be saying, no, I don't want you to come today. I don't feel like it could be things like that. Um, sometimes they're just more quiet or, or they get cranky in ways that they didn't before. Like they're, you know, they're giving kind of more terse answers than what you maybe remember from before. So that could be a sign that they're having more pain or other symptoms. Some we use A, we use some AI software that actually kind of looks for some of the more subtle changes. Um, it can, it pulls the vital signs, so it can start to look for those. It can look for hospitalizations, it can look for, um, you know, symptoms. It can really start to kind of pull those pieces together that maybe the human eye doesn't see when we're in there every single day. Um, so I think there's a lot of ways that we can find those little subtle signs that are coming at us.

Speaker B: That's great. And once you recognize that those signs, the next step is knowing what to ask. What are some practical questions clinicians can ask to better understand what matters most to the patient?

Speaker A: I have found that if you have a conversation that doesn't start with us asking them, you know, how do you feel about dying? Or I think if we can start the conversation in a less hospicey space, it can be more successful. Um, I try to teach clinicians to really ask them, what do you understand about your disease? What do you understand about the prognosis of, and the trajectory of what's happening with your body? Like, what do you understand clinically? Um, and then based on that, what do you, you know, what has your doctor said about your prognosis? Like, what has your doctor said about how long you, um, would be able to, to continue on with this diagnosis? And, and sometimes if, if they don't really truly understand their, their disease, their diagnosis, um, that might be a question back to the doctor. Like, they don't understand that they are at end stage heart failure. You really need to have a conversation to help explain. You know, nurses can't give prognosis, but we can, we can encourage the doctor to have that conversation. Um, I remember also I've, I've encouraged patients, don't ask, don't ask the doctor how long you have to live. Ask them how long other people with a similar diagnosis and similar symptoms, how long they have lived. Because that takes a little bit of the pressure off because doctors can't, they don't have a, they don't have a, you know, crystal ball. They can't see the future. But they, they know data and they know what the data can show for people in a certain place. Um, and then once you have those questions answered, okay, so based on, on these things, like, what are your goals, what's important to you? Um, and kind of exploring that for a bit, and then once you know what those goals are, okay, how can I help you meet that? How can I help you get there? Is it do you need a social work, uh, consult to come in and help fill out advanced directives? Um, do you need me to call somebody, you know, to get you more information on what's happening? Um, do we need a hospice referral? You know, what. What does that look like? So, considering that, you know, and what's important, I mean, it's interesting how there's. There's an event that can often be an event that people really want to get to, and how can we help support them in getting to that too? So it's just. It, it's a, it's a, it's a, It's a conversation. And I think it's a conversation we could use for everyone in chronic with chronic illness to really explore. What do they know, what's important to them and what do they want? Um, as they go along.

Speaker B: Yeah, really important skills. And I don't think they, they always come naturally to use me. Support and practice.

Speaker A: Right.

Speaker B: How do you help clinicians get more comfortable with these conversations?

Speaker A: I think, I think you can do it in a variety of ways. Um, you can have clinicians go, like, on a co. Visit with a, um, experienced clinician so they can kind of see it happen. Um, and sometimes it's really helpful, like if it's their patient that they have a more experienced clinician that they could call to come in and visit with them and have a conversation. Um, sometimes you kind of even make appointments for the conversation. So bringing in the right people can be helpful. Helpful. Um, I think role playing in a safe setting is really important. Um, having the opportunity to kind of pretend you're having this conversation. Um, but I think as. As, you know, I think we also need to make sure the clinicians really fully understand the benefit, um, of hospice and what that, what that insurance benefit entails. Um, because, you know, sometimes, you know, we have to really kind of look at. Have them, you know, what can we tell them about the benefit? The, the, you know, that maybe is less scary than them hearing the H word and talking about hospice person.

Speaker B: So. So you mentioned role playing, which probably makes some a little uncomfortable, but it's not the favorite. No, sounds important. Um, why do you think role playing matters so much, Especially in conversations where you may only get, you know, one chance to do it well.

Speaker A: Right. I think it's like any other new skill. Um, the first time you, you know, maybe go bowling, it feels really awkward and you've got to figure out, and, and how do I hold this ball? And, you know, and not to mention it. It feels awkward but then you've got all this nervous energy, like, oh, my gosh, I haven't done this before. What if I screw this up? I'm gonna scar them for forever, you know? Um, but. So that's why I think it's really important. What we used to do is we would break up into small groups of three or four, and one. One person would be the nurse, one person would be the patient, and one would be like, either a spouse or a child. Right? And so, um, we would then present a scenario, and they had to kind of talk through the scenario. And there were. I usually gave them three scenarios because they all took turns, because I said, if you're going to be the really annoying daughter, well, then you're. She's going to get the chance to be the annoying daughter better for you. So, um, but I think, you know, in those smaller. Those smaller groups are a little less scary for people, you know, versus sitting down in the big room and talking through it. Um, but I think those, you know, outside of role playing, again, I think having those opportunities to. To shadow or to go along or have somebody go along with you can be really important.

Speaker B: Love that. Uh, I think another challenge is that even when the conversation is handled well, families often bring a lot of misunderstanding about hospice into it. What. What are some of the biggest misconceptions patients and families still. Still have about hospice?

Speaker A: I'll never forget my little lady. I had a. I, uh, had talked. Talked everything through. She's like, okay, this sounds great. And she goes, I'm ready to go to hospice. And I said, perfect. She started getting up. I'm like, where are you going? She goes, well, I'm going to pack my bag. And I'm like, you're not going anywhere. So I think people think it's a place that you go. And granted, there are residential hospices and they're. They're beautiful places. But for most people, hospices, wherever they are living and wherever they're calling home, um, so they think they have to leave their home. They think they won't. I know another fear I've heard is that, well, if I fall and break my hip, I'm not going to get any treatment. Um, you will get some treatment. Nobody's going to. To just leave you there in pain, you know. And so whether. And you know, we. Whether that actually, you know, some sort of surgery or we can manage the pain with. With a different medication regimen, whatever that might look like. Um, but they think that, you know, if that happens or, you know, or if they have pneumonia and they get a uti. We're going to let them die of that. And that's just not the case. Right. Um, I think they also feel like they're going to die right away. Like maybe they're dying tomorrow if they go into hospice. And, and the reality is data shows us people live longer hospice. So I think that's something that. That I think people are really surprised to hear about. Um, they don't realize they can revoke that once you. Once you, you know, elect hospice, you can revoke at any time if that's what you want to do. Um, and I just. I don't think they realize that it's an insurance benefit that they have paid into their whole lives. It's part of Medicare. Just like we pay taxes for the. For our Medicare coverage, hospice is that. And when we don't, you know, take advantage of that, that's. That's a whole benefit that we're leaving on the table.

Speaker B: Yeah, he talked about hospice as a Medicare benefit that, uh, people have, uh, paid into. And, you know, why does that framing help people understand hospice differently?

Speaker A: I think, um, I think if you start with talking about what the benefit offers, like, don't say the H word for a little while, like, hold on to that. Um, but talking about, like, the DME and the medication coverage, like, what that looks like, um, I've had people just. The family getting out to get the medications all the time. I mean, just having those medications delivered was. Was a huge, you know, a huge thing for them. The spiritual care, um, the hospice aids, the, you know, the veteran programs, all the different components. And really talking about what that looks like, looks like, um, and. And making sure they know that this is a benefit that's designed to support you in your final months of life. Um, it's something that has been carved out by Medicare for you and ops. It's called hospice. Um, I think ears tend to close when you say the H word. Um, so that's why I like to say it at the end so that they, um, they can actually hear what it's about before they. Before their ears shut up. That.

Speaker B: Yeah. It seems like once families understand it better, many of them look back and wish they had that conversation sooner. Have you found that families more often say, we wish we had started sooner rather than we started too early?

Speaker A: I've never had a patient say, man, I, um, wish I hadn't been in hospice so soon. I've never in my life heard that. Um, but I cannot count the number of times when Somebody has said, I really wish I had known about this sooner. I wish I had known what this was and how it could support me sooner. Um, I've heard that so many times. And that's why it's important that we, we move this work upstream the best that we can.

Speaker B: Love it. You also mentioned that technology started, uh, or is starting to play a role in helping teams identify patients earlier. What, what exactly can the. Can the software, the data or the AI help clinicians recognize, uh, hospice eligibility sooner?

Speaker A: Clinician assessment. I want to make sure this is clear. Clinician assessment is absolutely vital. It is of the utmost importance. But when you see a patient multiple times a week for weeks on end, um, you can miss out on those subtle changes. It's just like a family member. You don't necessarily, necessarily notice what's happening until, you know, until later on. And so the data is there. It can pick up, um, that's what it can pick up. Like subtle changes in vital signs or drops over time. I mean, we're going to notice if somebody's blood pressure drops off in one visit. We may not notice it over time or increases or their weight decreases. We may not be able to see that. Um, it is definitely not a replacement for the assessment of humans. But I think it's a great tool to help us open our eyes to somebody and at least ask the questions. Maybe somebody we wouldn't even have considered. Um, we have, I have, we have a wonderful team member who emails, who runs the reports and sends out every week to the clinicians, will send out, hey, these are the people that flagged through AI. What do you think? Like, what's going on with them? And so I think it's really been a helpful tool to help identify people a little bit sooner than we would maybe see to the naked eye.

Speaker B: Yeah, I think the people, people closest to the patient, you know, can miss that, that gradual decline, uh, simply because they, they see them so often.

Speaker A: Absolutely.

Speaker B: What, what can data pick up that, ah, even a, a good clinician might miss when, when they are seeing someone several times a week. I think you just mentioned like weight.

Speaker A: Yep. Weight, um, vitals, uh, hospitalizations are huge. I mean, I think weight loss, the amount of hospitalizations that people experience in the last, you know, year and months of life, it's really a huge indicator therapy, um, declines. You can start to see maybe therapy, subtle changes that are happening. Or it could be, or it could be a combination of the diagnosis, maybe there's another diagnosis that came along, um, and that when you pull it all together. Um, it kind of has triggers that it will, it'll, it'll grab and, and it's, it's just kind of all lives there in the data. So it's pretty cool.

Speaker B: One of the unique things about VIVI that you, uh, that you shared is that you operate across senior living, home health, and hospice. How does that create better continuity and better, better timing for hospice support?

Speaker A: I think that was one of the most exciting aspects of VIVI for me, was like, hey, we got, like, we really have the whole package here. Um, we can support them, you know, in the ALS and the SNFs, and, and really make sure they have the right level of care. Um, I think, and I think it truly comes down to collaboration and communication. Um, if an als, if an AL nurse or somebody in one of our buildings needs something, they just have to send a teams message to the person on the team. You know, hey, Bob's not looking good today. Come look at him. You know, whatever that might be. It's a quick teams message. Um, we also can document in EMR what we're seeing and what we're doing in the home, which I think is really helpful. Um, we've actually done a lot of work here in the Metro, digging in even since I got here to figure out what do you guys need? What, what, what would be helpful? Like, what, what would help improve this collaboration and coordination? And it's something as simple, you know, as having access to the emr, but also being able to, with our badges, being able to swipe in because we're, we're all vivi, being able to swipe in. When they're up in a patient's room at 2am and they' called for symptom support, we can get ourselves in. It's, it's even something as simple as that. So, um, you know, it just. And being able to partner. We. I, uh, was in a building this week and they were saying, you know, we really want to do more with veterans. And I'm like, well, we're a level four. We are veterans. Like, let's talk about this. How can we support you? How can we, how can we do that collaboration? Because, because we're all vivi, so it's good.

Speaker B: Love that. And since hospice is newer for VIVI in the, in the, uh, Minneapolis area, you're helping build something meaningful there.

Speaker A: Yeah.

Speaker B: What, what excites you about helping grow hospice in the. In, ah, the area with, with. Within that model?

Speaker A: Well, it's my home. Um, and as my family members progress, I mean, it's great to. To be able to know that, that the support is here. But there's so many things that I think are exciting. Um, VIVI is a. As a merger between two pretty large agencies in the state of Minnesota. Knut Nelson was the home health and hospice and Walker was the, um, in the. In the metro area had more of the buildings. And so having those two forces come together. Um, so, yeah, so the metro area did not have Knuth Nelson was not. They were more outstate Minnesota. So with this merger we've come in here and it just. There's such opportunity here. There's so many people who truly need great care. And so it's been really exciting to kind of watch those service lines come together. And, and we, you know, we have. We do work within population health and being able to really drive that and support people for the long haul. Um, and we can do it wherever they call home, you know, and that's been the beauty of it. But it's. It's really truly. I think it comes down to seamless care, making sure the patients and the families have what they need. If you have families that aren't living with them, they know there's somebody there, whether, you know, no matter who it is from our team. So I think that's what's so exciting. But yeah, it's really, it's amazing to have access to all of that and to be able to support and serve patients and families.

Speaker B: Love it. So we start to wrap up. Um, I want to bring it back to the. Maybe the leaders and the clinicians listening. For hospice leaders listening, what is one thing they should do differently to improve transitions into hospice?

Speaker A: Don't overlook your home health team as a referral source. They are a huge referral source for you. They are just as, if not more important than the hospital discharge planners, the clinics and um, the assisted livings and the different buildings. They are in a very important referral source. Um, and if you have a home health team or you have a partnership, invest in those clinicians. Make sure they have the resources they need. Make sure they have a good document that they can look at, clinical indicators or what the hospice benefit is, invest in them because it will come back. It will come back to you, and it will help grow your hospice.

Speaker B: Awesome. And on the front lines, it often starts with one good question. So for clinicians listening, what's one good question that, ah, they can start asking today that opens, uh, better conversations with patients and families?

Speaker A: I always think about Atul Gawande's book And there's a section in there where he talks about when you are talking, when you're, when you're working with a patient, you need to find out what baseline, what level do they need to be able to get back to, to want to continue living. And so I always think about my dad, and my dad, if he could not eat ice cream and, like, watch television, he would not want to. I don't think he'd want to be here. And I. So I think it's important that, that we're, we're asking that and we're identifying that and if we could just ask them what's important to you? What is most important to you right now in your life and in your world? And I think, I think that whether you have somebody who's, you know, moving toward hospice or not, I think it's important that we ask our patients what is most important to you, what matters to you most now?

Speaker B: Yeah. Angie, thank you again for joining today. I really appreciate it.

Speaker A: My pleasure.

Speaker B: Really appreciate your perspective and the experience you shared with us.

Speaker A: Thank you so much. Oh, my pleasure. Be well. If you're looking to attract more families and share your hospice mission with a Wider community, visit hospicecaremarketing.com um, schedule to schedule your free consultation with marketing expert and founder link Ryan France. Plus, join our free hospice marketing mastermind group on LinkedIn to connect with other practice leaders and stay up to date with the latest strategies. If you enjoyed this episode, please take a moment to leave us a five star review. We'd love to hear from you.