Psychosocial Collaboration for Hospice and Palliative Care Patients

Psychosocial Collaboration for Hospice and Palliative Care Patients

Psychosocial Collaboration for Hospice and Palliative Care Patients in a Children's Hospital Nikki Helland, MSW, LICSW and Martha Schermer, MSW, LICSW, ACHP-SW Martha Schermer, MSW, LICSW, ACHP-SW is a clinical social worker for the Pain, Palliative Care and Integrative Medicine Department of Childrens Minnesota. She received a B.A. in Social Work from the College of St. Benedict and her M.S.W. from the College of St. Catherine and the University of St. Thomas. Martha began working with Childrens in 1995 and with Home Care and Hospice in 2001. Currently she works in the Department of Pain Medicine, Palliative Care, and Integrative Medicine. Martha works with families across the continuum of palliative care providing services in the clinic, hospital and in the home. [email protected] Nikki Helland MSW, LICSW is an inpatient clinical social worker at Children's Minnesota. She received a BA in Psychology and Family Resources from St. Olaf College and her MSW from the College of St. Catherine and the University of St. Thomas. Nikki began working at Children's Minnesota in 2009. Nikki provides primary coverage to the Pediatric Intensive Care Unit and Neuroscience Unit Medical/Surgical floor on the St. Paul campus. She has also provided interim coverage for neuro-oncology within the Children's Minnesota Cancer and Blood Disorders team. [email protected]

2017 Objectives Demonstrate the ability to collaborate with social work peers to ensure excellent psychosocial care. Identify potential sources of conflict in the working relationship. Apply strategies discussed in this presentation to address conflicts 2017 Childrens Minnesota

2017 One of the largest freestanding pediatric health systems in the United Stateswith two hospitals, 12 primary care clinics and six rehabilitation and nine specialty care sites. The only health system and Level I Trauma Center in Minnesota to provide care exclusively to children from before birth through young adulthood. An award-winning health system, regularly ranked by U.S. News & World Report as a top childrens hospital. An independent and not-for-profit system (since 1924). Palliative Care at Childrens The Palliative Care Program at Childrens MN provides clinic, hospital, and home-based services to patients and their families. Our team consists of physicians, advance practice nurses, psychologists, registered nurses, social workers, child life specialists, chaplains, and volunteers. Our home-based services include both hospice and non-hospice palliative care for children with life limiting diagnoses who live within our service area of 30 mile radius from either hospital (this includes

most of the metropolitan area surrounding St. Paul and Minneapolis). 2017 Social Work at Childrens Children's Minnesota employs clinical social workers with graduate level degrees and licensing through the Minnesota Board of Social work. The department includes 14.7 FTE social workers providing primary inpatient coverage during weekdays. There are 4.3 FTE Hematology/Oncology, 3 FTE Mother-Baby and 2 FTE within Pain/Palliative Care who provide both inpatient and ambulatory support. There are 5.8 FTE social workers devoted to outpatient clinics providing integrated behavioral health and care coordination. Additionally, there is in-house coverage during weekday evenings and overnights, telehealth, on call and daytime in person weekend coverage. 2017 Theoretical model of ward social workers collaboration with palliative care

social workers (Firn et al. BMC Palliative Care, 2018, 17:7) 2017 How do we work together to meet the needs of the patient and family? 2017 Who has the relationship with the family? What is the medical team requesting of Palliative Care? Strategic introduction or intervention for transfer of trust? Who has availability?

What are the family needs? Where will most of care occur (at home or in the hospital)? Which team will be primary? Is there a timeline to consider for continued hospitalization, discharge to the community, and/or trajectory of the illness? Will both social workers stay involved (what makes sense)? Case Study 1 Elisabeth 2017 2 year old female, presented with altered mental status

Parents never married, joint custody going between two households, paternal grandparents very involved, two maternal siblings, family lived in Wisconsin, over an hour from hospital Preliminary diagnosis of leukodystrophy (rapidly progressing), just prior to discharge diagnosis clarified as HLH by genetic testing Hospitalized for 10 weeks on med/surg Near daily needs of social work and with multiple care conferences throughout stay Out of service area for Childrens hospice program Both parents concerned about the other parents capacity Parents were eventually able to make a plan together, although the tension never completely resolved Case Study 2 Chelsea

2017 Newborn with septo-optic dysplasia which was not a unifying diagnosis, patient had multiple complications involving multiple subspecialties 6 week NICU stay, discharged to foster care, readmitted two weeks after discharge and hospitalized for almost 4 months, on PICU and med/surg, extreme medical fragility with concern for survival Mother with significant mental health and chemical dependency, homelessness, lack of insurance, FOB not involved, allegations of domestic abuse, MOB was quite disengaged-profound anxiety which made it difficult for her to come to/be at the hospital MOB ended up rooming in due to homelessness and ultimately was asked to leave hospital due to concern for drug use Inconsistent ability to contact mother, but retained legal decision making authority Lost foster care in February, new foster home identified in March CPS and court appointed guardian ad litem *POLST

Case Study 3 Karen 2017 15 year old female seen in the ED due to headaches, diagnosed with left thalamic/midbrain/temporal lobe H3.3K27M mutated glioma, over six month period underwent resection, radiation and vaccine trial, presented approximately six months later with SMART syndrome Intact family, financially secure, no over arching social concerns, four younger brothers, mother distressed that Make-a-Wish referral was incomplete, mother presented with anxiety in response to changed prognosis Family opted for end of life care in the hospital Primary SW no longer at hospital, lack of information about previous

work done with family Survey Questions 2017 Have you found your interactions with the palliative care team to be collaborative? Have you found your interactions with palliative care social workers to be collaborative? When you have collaborated with palliative care social workers, has information sharing has been effective?

When you have collaborated with palliative care social workers, has role negotiation been effective? As a clinical social worker, do you feel your skills and abilities are respected by palliative care social workers? When you have collaborated with palliative care social workers, have the needs of the patient and family been met? Has your role within the care team been respected by palliative care social workers? Do you find it helpful to have end-of-life/goals of care discussions with the assistance of the Palliative Care staff? Please identify potential areas of conflict or barriers to collaboration in your working relationship with the palliative care social workers. Please comment below. Please identify what has contributed to effective collaboration. Please comment below. Trust (Ability, Benevolence & Integrity)

With palliative SW having the lens of end of life, having their partnership when holding difficult conversations with families has been very effective and appreciated. The compassion and competency demonstrated by palliative care has made me so happy to work with them - I feel this huge sense of relief when I see them coming my way. I highly value palliative care and their role in a medical setting. Their services are fantastic and when collaboration is done well it can be amazing to see the affects it has on the family and care team. I have had mixed experiences working with the pain and palliative providers. Some do much better at understanding the clinical/therapeutic work of social workers. I find that my own medical team seems to understand and appreciate clinical social work, so it is disappointing when psychologists or other providers on the palliative team have a limited understanding of the strengths of social work support to patients and families. *Our recognition of the skills and abilities we each possess is imperative to fostering trust. 2017

Trust (Ability, Benevolence & Integrity) I have found my collaboration to go well with the palliative care social workers. The social workers always reach out to me as the primary clinical social worker who has followed the family throughout their initial care. Then when the patient is at home, the palliative care social worker becomes primary but continues to consult me and allow the family to call me when they feel comfortable talking to me as well. It gets a bit more complicated when the patient is inpatient, but generally the palliative care social worker and I are in close communication to talk about roles, support for the family, and engagement with the medical teams. Mutual respect. Communication. Clear expectations. Advocacy for role w/in teams. (Information Sharing & Role Negotiation) Shared understanding of patients prognosis and the family's goals and experience with patients medical journey. How nice the palliative care social workers are does help - as I have found them

kind and open to collaboration. *Our expression and demonstration of benevolence toward one another and integrity in our work with patients/families is essential to a trusting relationship. 2017 Information Sharing At times I may not know if/when palliative care SW is or is planning to follow patients. Most of the time, it's noted, but it can be a challenge as we don't have as close contact with palliative care SW, unless we share patients. It may be considered a barrier, that we don't office together, cross paths in our day to day work, etc. so maybe a mainstreamed way to communicate and/or check in about shared patient could be helpful. The collaboration itself has been wonderful! Clear communication via email, phone and in-person. It was helpful to get a call immediately from the palliative care social worker

when the worker became aware that she would be involved with a patient that I am already supporting. (trust) *Consistent communication by phone and in-person has been critical to effective collaboration. Email, paging and EMR review has been important for coordination and brief updates. Communication needs to be initiated by both parties. Maintaining an open invitation to have inpatient SW join initial and ongoing consults when possible fosters the relationship and contributes to the care of the patient and family. 2017 Role Negotiation With overlapping roles, responsibilities need to be negotiated on a case by case basis. The unit social worker often has greater availability to meet with families quickly and repeatedly through the course of a day or week Clear discussion about responsibilities and roles helps to insure needs are

being met most effectively. The two of us social workers meeting or talking by phone regularly about our roles, what we are doing with families, etc. The palliative care social worker reaching out to me. The palliative care social worker respecting what ways I can be helpful to the family and us discussing who can do what to be helpful for family (trust & info sharing) *Determining role negotiation on a case by case basis requires flexibility. Review how to best meet the needs of the patient and family (refer to questions on slide 9). Mutual respect and efforts for equitable distribution of labor as possible, all supports role negotiation. 2017 In closing Just as we know a focus of Palliative Care is the relationship with patients and families, we need to recognize that our relationships with other social workers are vital to ensuring that patients and families receive good care. "The most important single ingredient in the formula of success is knowing how to get along with people."

Theodore Roosevelt 2017 Bibliography 2017 Ambrose-Miller, W., & Ashcroft, R. (2016). Challenges Faced by Social Workers as Members of Interprofessional Collaborative Health Care Teams: Table 1:. Health & Social Work, 41(2), 101-109. Code of Ethics. (Revised 2017). Retrieved from https://www.socialworkers.org/about/ethics/code-of-ethics Feudtner, C. (2007). Collaborative Communication in Pediatric Palliative Care: A

Foundation for Problem-Solving and Decision-Making. Pediatric Clinics of North America, 54(5), 583-607. Firn, J., Preston, N., & Walshe, C. (2017). Ward social workers views of what facilitates or hinders collaboration with specialist palliative care team social workers: A grounded theory. BMC Palliative Care, 17(1). Quick Guide Making Interdisciplinary Collaboration Work. (2013). Retrieved from https:// www.socialworkers.org/LinkClick.aspx?fileticket=pT-gXK-tD7M%3D&portalid=0

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