IMPROVING PALLIATIVE CARE WITHIN NHC Jamie Slandzicki MD, CMD Chief Medical Officer, PASS (division of NHC) Why discuss Palliative Care? Why now? Why this environment? What does this mean? Why do we all need to be involved?
The purpose of a doctor or any human in general should not be to simply delay the death of the patient, but to increase the persons quality of life - Dr Hunter Patch Adams Case Scenario 85 year old white female admitted to NHC from area hospital after treatment for CHF exacerbation PMH: diabetes mellitus, COPD, hypertension, CAD, CHF, atrial fibrillation
After 1 week in SNF patient develops increasing shortness of breath, decreased O2 saturation and mild substernal chest pain. Pt is transferred back to the hospital for 5 days and stabilized then readmitted to NHC After 2 weeks patient is noted to have significant leg edema and 10 lb weight gain Diuretics increased but not helping and after 2 more days patient is transferred back to the hospital Case Scenario 76 year old white female with moderate dementia admitted after surgical treatment for hip fracture
PMH: osteoporosis, dementia, CAD, history of stroke, HTN, history of breast cancer, recurrent UTIs, history of GI bleed Patient on warfarin for DVT prophylaxis Patients family requests CPR and full treatment on POLST form Case Scenario 65 year old admitted from area hospital for rehabilitation following total knee replacement PMH: HTN, hypercholesterolemia, fibromyalgia, and depression due to recent loss of spouse After several days at NHC, it is apparent that
patient is not progressing as well as expected due to pain and lack of motivation How should the care of these patients be individualized? Which of these patients should receive palliative care? Whose responsibility is it to take the lead in addressing the specific issues in each of these cases? Why are we discussing Palliative Care?
PASS The mission of Post-Acute Service Solutions is to be a resource to patients and or episode initiator partners to assist in guiding patients through the episode and to track the progress of patients from care setting to care setting, communicate and report to the patient and all of the stakeholders in the patients care PASS values the lives and health of each patient. PASS is committed to do the right thing for the patient, as we work to elevate them to their optimum level of health Hospitals are heavily focusing on Palliative care in the acute setting Response to hospitals expectations of a post-acute Palliative Care Program
As a leader in the industry NHC must be proactive in the care of our patients and drive outcomes, rather than to take a reactive approach What is Palliative Care? Palliative care, also known as palliative medicine, is specialized medical care for people living with serious illnesses. It is focused on providing patients with relief from the symptoms and stress of a serious illness whatever the diagnosis. The goal is to improve quality of life for both the patient and the family. Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment.
Barriers to providing quality palliative care in nursing homes Poor transfers between hospitals and nursing homes Staff recruitment and turnover Training and educational needs Cultural differences Family expectations and misperceptions What is the Difference Between Palliative and Hospice Care?
Palliative Care Hospice 1. The objective of both hospice and palliative care is pain and symptom relief. 2. The prognosis and goals of care tend to be different. Hospice is comfort care without curative intent; the patient no longer has curative options or has chosen not to pursue treatment because the side effects outweigh the benefits. Palliative care is comfort care with or without curative intent.
Hospice eligibility requirements In order to be eligible to elect hospice care under Medicare, an individual must be entitled to Part A of Medicare and certified as being terminally ill by a physician and having a prognosis of 6 months or less if the disease runs its normal course. Need for palliative care in the nursing home setting 1. Increased Proportion of Dying Patients in Nursing Homes By 2030 the number of people living in nursing facilities in the US is expected to
double to over 3 million 2.Increased medical acuity of patients admitted to Nursing Homes 3. Nursing Homes Held Accountable for Quality 4. Nursing Homes Are Likely to be Penalized for High Readmission Rates 5.
Reimbursement Shifting to Pay For Performance Where do Americans die? Studies have shown that approximately 80% of Americans would prefer to die at home, if possible. Despite this, 60% of Americans die in acute care hospitals, 20% in nursing homes and only 20% at home. A minority of dying patients use hospice care
and even those patients are often referred to hospice only in the last 3-4 weeks of life. Untreated or under treated pain in nursing homes is well documented 65% of nursing home residents need help with 3 or more ADLs A study in 2000 revealed that at least one-third of nursing home residents in the U.S. suffer from malnutrition or dehydration In 2014, the Institute of Medicine released its report
Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. The Institutes recommendations emphasized the importance of palliative care training and education. Specifically, the report addressed the following: The importance of symptom management
Effective communication Advance care planning Goal based care Continuity across settings while addressing patients social needs NHC PALLIATIVE CARE COMMITTEE In late 2016 an internal evaluation of palliative care provided by NHC resulted in the recommendation for an updated and more consistent palliative care pathway throughout NHC including SNF/Long Term Care and Home Health An NHC palliative care committee was thus formed, and members continue to
meet on a regular basis with the purpose of program development and implementation, first focusing on palliative care in the SNF/long term care setting The committee consists of NHC representatives from nursing, social services, pharmacy, clergy, physical therapy, home health, hospice, administration, and a medical director. Four members of this committee attended the annual CAPC (Center to Advance Palliative Care) meeting in Orlando last October to gain valuable information needed to develop a corporate wide palliative care pathway across post-acute settings. The committee collaborates with area hospitals to develop pathways for smooth transition from the acute setting to the post acute environments.
Pharmacist Role Excessive medication Nontraditional administration routes Individualized care Gastrointestinal issues
Psychological issues Tapering or discontinuing medications Metro Nashville South Central North Eastern Clergy Beth Dault
Dr. Slandzicki Dr. Donald Vollmer Christie Piland Josh Fralix Joan Stephens Teresa Shoaf South Carolina
Eastern Pam Owens Lynn Knott Rehab Missouri Central Models of Palliative Care in the Nursing Home Setting
The Health Affairs blog, published in December, 2013, describes three models for delivering palliative care in the nursing home. Hospice agency/nursing home partnerships This is a partnership between a hospice agency and a nursing home, where eligible nursing home residents access their Medicare hospice benefit. An eligible resident must have a prognosis of six
months or less if the disease runs its normal course and must waive other Medicare benefits upon election of the hospice benefit. About one third of nursing home decedents now access the Medicare hospice benefit before death. Hospice can bring expert symptom management, personal care services, social work services for families, other Externally based palliative care An external palliative care consultation team works with nursing home clinicians to serve a
broader population of nursing home residents, including those with chronic illness. To access palliative care services, there is no need to forgo curative treatments to receive services. The consultant, a physician or nurse practitioner, bills under Medicare part B; therefore costs for these services are not incurred by nursing homes. Facility based palliative care A facility may develop palliative care expertise within its own facility, allowing the creation of palliative care services that meet the needs of
their residents. Staff training in the nursing home is critical to the success of this model, and to fostering a culture where a palliative approach to care is welcome and widely supported. Support for staff training and the understanding of the palliative approach to care may be a service that a hospice organization can provide to help palliative NHC Pilot The pilot program will focus on palliative care in the skilled/long-term care centers. Implementation of the pilot program began July 1, 2017. 2 centers representing two regions have agreed to participate in the pilot program
NHC - Murfreesboro NHC Healthcare - Franklin HPCC certification (Hospice and Palliative Credentialing Center) will be obtained by the appropriate nurse practitioners and nurses. http://hpcc.advancingexpertcare.org National Association of Social Workers (credentialing for social workers) http://www.socialworkers.org NHC Pilot Each center will have representatives from nursing, social services, and a nurse practitioner who will serve as team champions. They
will collaborate with the director of nursing and palliative care committee to identify and educate appropriate personnel at the centers who will comprise the palliative care consult team. NHC has purchased a CAPC (Center to Advance Palliative Care) membership for the two pilot centers in order to obtain necessary educational materials and other resources essential to developing the program. http://www.capc.org The Center to Advance Palliative Care (CAPC) is the nations leading resource for palliative care development and growth
Mission The Center to Advance Palliative Care is a national organization dedicated to increasing the availability of quality palliative care services for people living with serious illness. Vision CAPC is an organization with a simple vision palliative care everywhere. Mission and Vision carried out in 3 ways: Improving the knowledge and skills of all clinicians who serve seriously ill patients and their families Helping health organizations to reliably support and deliver high quality palliative care to patients and families in need Increasing public understanding of palliative care so that all patients and
families will know to ask for it when faced with a serious illness NHC Palliative Care Committee The committee recognizes and respects the autonomy and differences of each center and region and will work collaboratively with Medical Directors and Administrators of each center and region The program is designed to be supportive and will serve as a resource to the centers Direct medical care of patients will not be provided or dictated by the committee members or the Palliative Care Medical Director
The committee realizes that there will be some differences operationally in each center based on Topics of focus and development Criteria for Palliative Care Consults Identification of patients who have had palliative care consults in the hospital Clinical pathways by diagnosis Communication and collaboration Education Metrics and measurements Pharmacy
Advanced Directives Metrics The following measures will be evaluated during the pilot program Readmissions Medication costs Number of medications per patient Pain control Patient satisfaction We anticipate the duration of the pilot program to be 12
months. Upon evaluation of the pilot program, the palliative care committee will make recommendations regarding implementation across additional NHC centers (Phase 1) Phase 2 will involve extending the program to patients in the community setting to include home health and hospice services. Discussions and preparation for this will begin in conjunction with the phase 1 pilot program. Challenges in the Post-Acute Setting Medical Director involvement
Physician/Nurse Practitioner Billing No extra payment to centers for providing palliative care to patients Hospice does not cover room and board in SNF Misperceptions of palliative care Questions? Jamie Slandzicki, MD, CMD Chief Medical Officer, PASS [email protected] om
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