Learning by Trial and Error
Hospice in the Assisted Living: the ‘How To”.
NHPCA Conference 2011 By LaDonna VanEngen RN, CHPN HealthConnect at Home-Saint Elizabeth
Recognizing the Need for Training Obvious to Everyone
Old Model of Objectives Cure-Care Continuum
Recognize the benefits of hospice and palliative care. Recognize barriers that may impede provider relations and delivery of services. State 2 ways hospice and the ALF staff Curative Palliative can promote optimal team functioning. Care Care Identify how Administrators attitudes effect hospice care in their facilities.
1 Next Model of Cure-Care Continuum
Hospice Threshold B e Where We Want to Be H r Curative o e Care s a p v i e Palliative c m Care e e n t
Adapted from R Ackerman
Goals and Emphasis of Care Goals and Emphasis of ASL
HOSPICE ASSISTED LIVING HOSPICE ASSISTED LIVING Medical Model Social Model Team Patient/family 24hr Care giving Assisted care Communication communication with available. according to contract Skill in Care of Dying staff Professional in Patient/family in & Bereaved Staff is grieving charge of Plan of charge of Plan of Continuity of Care Staff not experts in Care Care Across Settings care of dying. Attention to Relief of Life Closure Staff is family Suffering Quality Improvement
Determine goals & elements Resident Population
Flexible enough for growing & changing Includes residents experiencing a needs of residents & facility debilitating, life limiting condition Program goals are for facility & not for Population of nursing facilities divided individual residents or families, should be into 3 groups of residents with: complimentary short-term rehabilitation chronic long-term diseases terminal illnesses
2 Resident Population: Assisted Resident Population Living
Expand or narrow program as facility AL residents likely to have chronic conditions & may be experiencing progressive decline adjusts to changes in philosophy, care Some AL facilities specialize in end of life care & may practices, & population expand care focus to palliative care Requirements for extensive assistance with ADL’s & Facility needs to select what population it complex medical needs supplemented by family & would like to target first community resources If requirements can be handled, resident will be able to remain in place throughout palliative care experience Some residents may experience needs that are beyond what an AL facility is equipped to provide
A palliative care program can serve Populations many populations:
People with Seriously & terminally ill residents who disabling or congenital conditions requiring LTC are unlikely to recover or stabilize & for acute, severe illnesses where cure is goal, whom care will be needed until death but illness & treatment challenging to residents & families families need care through death & progressively chronic & debilitating bereavement conditions or symptoms, or diseases that People identified as suffering cause symptoms that are difficult to manage People who meet Medicare guidelines for hospice admission.
Inclusion into a palliative care Inclusion into a palliative care program determined by: program may be determined by:
Symptom management Use of specific indicators, residents with two or Decline more may be added Diagnosis Examples of these indicators include the following: Weight loss Weight loss Identifying residents having unsatisfactory Ulcers outcomes, unmanaged symptoms, psychosocial issues, or other factors Increase in falls Infections Using hospice criteria for admission as a Change in mental status baseline Change in functional abilities Change in continence of bowel or bladder
3 Hospice Eligibility Resident & Family Centered Care
Medicare Benefit Policy Manual Recognizes uniqueness of each resident & family An individual is eligible Resident defines family has a terminal illness with a life Family expectancy of six months or less people who support & care for resident & those the resident has a significant relationship if the terminal illness runs its normal Resident & family determine goals & course. preferences for care planning Health care team supports & guides family & resident in decision making process
Medicare Benefit Policy Manual ;Chapter 9 - Coverage of Hospice Services Under Hospital Insurance http://www.cms.hhs.gov/manuals/Downloads/bp102c09.pdf
Questions to ask Timing of Palliative Care
What are residents’ expectations of care? Palliative care begins with diagnosis of life What does resident want? limiting condition & continues to a cure or until death & into bereavement for family Does resident want to live no matter what? Resident’s condition may deteriorate, or may Does resident want to be kept comfortable regardless of treatment effects? come to facility already diagnosed Evaluated on admission for palliative care Is it more important to be alert than it is to be comfortable? program with a formal identification tool Indicators should be identified on assessment Do they expect to go home from facility after a recovery period? document Tool will depend on criteria facility identifies for Do they understand if they have a terminal illness? inclusion into a program
Comprehensive Care Comprehensive Care
Holistic multidimensional analysis to identify & Set up guidelines so care planning team work to relieve suffering automatically evaluates residents who Requires regular resident-centered processes for: may benefit from palliative care assessment Recommendations relating to care made diagnosis by anyone, with criteria care planning interventions Resident’s goals for care guide evaluation determining if should be in palliative care follow up program
4 Additional team members to Interdisciplinary Team consider
Palliative care team set up to meet Volunteers Direct care staff resident’s needs Bereavement Dietitians specialists Include individuals based on services Activities needed Hospice employees coordinators Chaplains Case managers Core team members include members from medicine, nursing, & social work Psychologists Specialty therapists Pharmacists (physical, occupational, speech)
Attention to Relief of Suffering Nebraska Information
Primary goal to relieve as much suffering 20 Assisted living and LTC facilities & burdens imposed by illness & interviewed and 6 different Hospice treatment as possible agency team members (Social Workers, and RN’s) asked ‘How should hospice Suffering occurs from many areas be done in the assisted living facility?’ Suffering in one area often influences ‘What does Hospice look like when it is another done right?’ Identifying cause of suffering can aid in Facilities were from Scottsbluff to alleviating Omaha.
Communication Skills
Good communication skills necessary Skills include appropriate & effective sharing of information active listening determining goals & preferences assisting with medical decision-making effective communication
5 Communication ideas/ASL Communication Ideas/ASL
Hospice can and should explain benefits. The same team members for all the Emphasizing that 24 hr care is not part of hospice patients in their facility improves the benefit. communication. ASL staff and hospice staff should set up Notify staff of changes in plan of care. initial care plan with patient/family input. Communication books Hospice should come out in 24-48 hr Resident chart documentation. after referral. Notify who is going to obtain physician orders. Update if orders not obtained.
Communication Ideas/ASL Communication Ideas/ASL
Educate staff (med aides) as to what to More counseling and one on one would look for and when to call hospice team. be helpful. ’Don’t assume we know”. Hospice should ask ASL staff ‘What do you think?’ Using the resident’s pharmacy for drugs works best and getting emergency drugs Do everything the team can to keep the from their own sources. resident in their ‘home’. Resident’s service agreement needs to be updated. Copy for hospice to see if needed.
Provide what is promised Communication Ideas/ASL
Let ASL staff know before discussing with resident and family that resident may be discharged. Standing orders are helpful. Hospice can build relationship with family. Range orders don’t work.
6 Communication Ideas/ASL Communication Ideas/Hospice
Identify types of services needed: how Call referrals even when not sure if often and by whom. Include waiver resident qualifies for hospice benefits. workers, and private caregivers etc. Make time to have staff available for Clearly identify who does what and developing the initial Plan of Care. update the resident. ASL should identify who to communicate Hospice should attend all deaths, with and how. (cell phone to MA on call) especially when asked to come. or charge nurse?
Communication Ideas/Hospice Communication Ideas/Hospice
Death Policy in place so we can follow it. Help ASL staff to recognize grief and not With waiver residents-who is responsible view it as a weakness. for communication POC to them. Allow time to have ASL staff express ASL to instruct Hospice RN’s as to the their feelings, needs and concerns. procedure for obtaining physician orders Use communication book but write only and documentation in their facility. what anyone could read. Use voicemail, ASL staff to notify Hospice RN when emails, phone calls etc. there is a significant event e.g a fall.
Communication Ideas/Hospice Communication Ideas/Hospice
Use standing orders but don’t order Leave written communication in place meds until they are initiated. ASL staff will read it. Order meds without ranges so MA’s Hospice should be proactive with total don’t have to call and/or make assessments. assessments and decisions. Get staff input before making changes in Order meds on a schedule and see more POC. often in order to assess for side effects Share family dynamics and concerns. and effectiveness.
7 Skill in Care of Dying & Are we listening? Bereaved
Team members must be knowledgeable in caring for needs of dying residents & families Must also be knowledgeable in: prognosis signs, & symptoms of dying bereavement issues grieving process age specific needs Referral to a hospice program
Continuity of Care Across Continuity of Care Across Settings Settings
If resident has injury or illness that is a Collaborate to ensure change in condition Hospice should be quality care, notified. effective communication, If ambulance transfer is necessary continuity of care Hospice should be notified first to emphasis on preventing crisis & arrange or approve. unnecessary transfers Palliative care works to prevent crises
Barriers Impeding Relations Perceived Barriers-Attitudinal and Delivery of Services
Late referrals “owning” their settings Miscommunication or lack of “knowing what is best for the patient”, communication between ASL staff, Distrust toward hospice Hospice team, resident / family and Emotional state caregivers. No choice in hospice agencies Lack of respect and awareness of each
team member’s abilities and roles. Journal of Palliative Medicine,Perceived Barriers that Impede PRovider Relations and Medication Delivery: Hospice Provicers Experiences in Nursing Homes and Private Homes. vol 13, Number 3, 2010 48
8 Perceived Barriers-Site readiness Administration is key
Ill-defined hierarchy Administrators were surveyed and the Poor communication top four elements it reflected were emotional/social support, quality of care, Disagreements among care providers rapidity of death, and end of life care Responsibility overload coordination. Differences in care priority, education End-of-Life Care coordination received and training. Not ready to accept the most favorable rating overall. Hospice guidance. Jounal of Palliative Medicine,Percieved Barriers that impede PRovider Relations and Miedcation Delivery: Hospice Providers' Experiences in Nursing Homes and Private Homes, Vol 13, Number 3, 2010. 49
Administration is key Equitable Access
Need to be committed to concept of Access to palliative care available to all Hospice and what it takes to provide it in residents regardless of: the facility. Age Give residents options for care settings Race when level of care is highest. Ethnicity Residents will stay in their ‘home’ with Sexual preference adequate planning, education and Ability to pay support.
Quality Improvement Quality Improvement
Committed to high quality care Promoting better quality of life Evaluated regularly & systematically Core areas focus on safety & reducing care- Providing treatments & promoting total giving errors body health can help avoid additional Other areas for improvement include: suffering, stress, & symptoms Timeliness Resident-centered approach Effectiveness Accessibility & Equitableness Evidence-based Practice Efficiency
9 Promoting Good Quality Care Promoting Good Quality Care
Quality and nature of resident-staff and Respectful collaboration ASL-hospice staff relationships are Clear communication, use of critical. complementary knowledge and skills of Length of Stay in the facility and how staff well the staff knew resident associated Shared expectations about the care. with quality of resident-staff relationship. ASL administrator support for residents dying in place with hospice services.
Gerontologist, 'Hospice in assisted living:promoting good quality care at end of life. 2009. Aug:49(4):508-16, Epub 2009 May 21. 56
Summary Four Things to Say Before Goodbye
Identifying residents who would benefit Forgive me from a palliative care/hospice program I Forgive you Set guidelines that allow flexibility to Thank you meet needs of residents who are I love you suffering Goodbye! Education on communication skills, care of the dying, interdisciplinary team, & quality improvement processes
Ira Byock MD (1997), 'Dying Well: The Prospect od Growth at the End of Life. New York, NY. Riverhead Books. 58
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