Communication can reduce opioid misuse in home hospice care
HOSPICES THAT PROVIDE care at home struggle to prevent the diversion or misuse of drugs critical to end-of-life care, but some key practices can make the process easier.
Patient education and communication are critical, experts say, especially at the time of admission. Some states, including Delaware, mandate that hospices educate patients and their caregivers about drug disposal policies and procedures when patients are admitted. Hospices often include this information in orientation materials and have their admission staffers review the policies and practices with their patients and caretakers.
“It’s very important that the family understand that we’ll be disposing of the drugs at the end of care and how that works,” said Judi Lund Person, vice president of regulatory and compliance for the National Hospice and Palliative Care Organization.
Open dialogue sets expectations and illuminates the risk of diversion or misuse. Opioid treatment agreements, which may include informed consent documentation, allow patients and providers to discuss the risks and benefits of using opioids to manage pain and to develop a care plan. Providers can use these discussions to help screen and plan for possible drug diversion or misuse.
Kentucky-based Bluegrass Care Navigators uses the Opioid Risk Tool—a self-reported, proven screening tool—to vet all patients who receive controlled substances. If patients or their families are at risk, the organization will carry out a care plan to address substance abuse and diversion.
It’s essential to treat every patient and family equally to ensure that they don’t feel like hospice staff are targeting, policing or accusing them, said Dr. Salli Whisman, senior hospice medical director for Bluegrass Care Navigators.
Hospices should communicate that “safe medication practice is, ‘Just what we do for all our patients,’ ” she said.
If a hospice suspects a patient’s medications are likely to fall into the wrong hands, they can limit and document the number of drugs in the patient’s home.
For instance, “If drug diversion or medication issues are suspected, threeday supplies of medications are delivered in bubble packs and counted at each visit,” said Rebecca Gatian, chief clinical officer for Florida-based Avow Hospice.
Hospice staffers document medication counts in the patient’s electronic health record, which triggers an alert so that off-shift workers don’t refill prescriptions before they’re scheduled. If there are discrepancies between the number of recorded drugs and the amount present, the hospice begins a substance abuse and diversion care plan. Lockboxes can be used to prevent misuse.
Other ways to limit medications include using a patient’s prognosis to determine how much of a drug a patient will likely use, using long-acting medications to reduce the frequency of administration, or limiting the use of transdermal or continuous infusion medications to reduce the available opportunities for misconduct.
“We learned early that our process and education had to address the variety” of medications, said Tracy Neilson, vice president of compliance and education for Delaware Hospice.
After an in-home hospice patient dies, hospice staff should dispose of all medication as soon as possible—if the state allows it. Hospices should make sure to have a witness present when the drugs are destroyed and document disposal procedures in the patient’s record.
And while families and caretakers rarely decline assistance to destroy unused medications, they sometimes do. Hospice staff should document it and educate families about how to properly dispose of the drugs and provide the means to do so if possible.
In Ohio, Bella Care Hospice notifies the prescribing clinician and law enforcement if a family doesn’t want its staff to help get rid of unused medications, said Kelly Murray, senior director of integrity for Bella Care Hospice.
Unfortunately, there’s only so much that hospices can do to prevent drugs from falling into the wrong hands. When Congress was debating legislation to curb opioid abuse, a hospice relayed a troubling story to Lund Person.
“The daughter had a significant number of opioids in her hand and said, ‘No, you’re not going to dispose of these drugs. This is my inheritance,’ ” Lund Person said. “What do we do in that sort of circumstance? I think that’s a piece of this that every hospice is going to struggle with.” ●