Working Together Providing Quality End of Life Care

1. Working Together Providing Quality End of Life Care Presented by: Jan Nowak LBSW Brenda Schoenherr Social Worker Program Director Dowagiac Nursing Home RN, NHA, BBL, MBA

3. Interesting Statistic Did you know that the studies are showing that 10% to 20% of the residents in a Long Term Care setting, at any time, are appropriate for Hospice care?

4. Changes in the Environment • Decreasing Length of Stay • Increase in number of younger residents • Increase in complex/high tech admits • Increase in elderly care givers • Increase in working care givers

5. The Continuum of Care ACUTE CARE • Focus is on active treatment/intervention to cure, alter or prevent disease and/or to prolong life. • May include palliative care as part of the continuum. • Delivered by multiple disciplines in various modes.

6. Curative/Disease Focus • Diagnosis of disease & related symptoms • Curing of disease • Treatment of disease • Alleviation of symptoms

7. The Continuum of Care cont’d PALLIATIVE CARE • Focus is on relief of suffering and improving the quality of life. • May be combined with curative therapies. • Delivered in an interdisciplinary manner.

8. Palliative Focus • Pt/family identify unique end-of-life goals • Assess how symptoms, issues are helping/ hindering reaching goals • Interventions to assist in reaching end-of-life goals • Quality of life closure

9. Location of Death, 1997 www.chcr.brown.edu/dying/forresearcherssod.htm

10. Applicability of Palliative Care Life Closure Last Hours of Life Therapy to Modify Disease Palliative Care Bereavement Care Therapy to Relieve Suffering and/or Improve Quality of Life 6 Mos Death Presentation/ Diagnosis Illness Advanced Life-threatening Acute Chronic Hospice Care Attribution: Ferris FD, Balfour HM, Farley J, Hardwick M, Lamontagne C, Lundy M, Syme A, West P, 2001 Proposed Norms of Practice for Hospice Palliative Care, Ottawa, ON: Canadian Palliative Care Association, 2001

11. Hospice care is alwayspalliative.Palliative care is NOT always Hospice.

12. Why Partner? • A partnership between the nursing facility and the hospice interdisciplinary team provides the best approach to palliative care and optimal end-of-life experiences for dying residents and their family members.

13. Benefits • A partnership allows for: • Expertise by varied disciplines from both the hospice and nursing facility. • Collaborative care planning. • Resident and family involvement in decision-making.

14. Certification for Care • To qualify for hospice care a physician needs to certify that the resident has a life expectancy of 6 months or less if their illness runs its expected course.

15. The Medicare Hospice Levels of Care There are 4 levels of care provided by Hospice. 1.Respite. The resident is entitled to up to 5 days of Respite care usually provided in our contracted Long Term Care facilities to give the family a rest period from the care of the resident 2. Continuous Care. When the residents symptoms are out of control, Hospice will provide continuous care, 1:1 staffing. Examples of symptoms out of control include pain, severe anxiety, nausea/vomiting.

16. Level of Care, continued 3. Inpatient. The hospice resident may be admitted to a hospital or in a Long Term Care facilityfor treatment or symptoms out of control. An RN must be on the floor providing care to meet regulatory compliance. 4. Home Hospice Care. Hospice Home care visits are made to residents and caregivers to assess their needs. The facility is the resident’s home and the facility staff are also the primary caregivers.

17. Locationsfor Hospice Care Care can be provided in: • Home • Nursing Home • Hospice facilities • Adult foster care • Assisted living facilities • Hospital

18. RN MSW Physician Medical Director Chaplain Hospice Health Aide Volunteer Therapy Dietician Bereavement Interdisciplinary team

19. Medicare Hospice finances • The Medicare Hospice Care benefit does not pay for room and board charges. • Under the Medicare and Medicaid Hospice Care benefit the hospice does pay for: 1. Medications related to the terminal diagnosis 2. Durable Medical Equipment 3. O2 4. Therapy services when in the plan of care

20. Medicare Hospice finances continued • For services to be covered that are related to the terminal illness they must be a part of the hospice plan of care

21. Coordination and Collaboration The Hospice staff supplement the care plan with the additional problems, goals and interventions where applicable.

22. Coordination and Collaboration • The Hospice personnel should conference with a facility staff member to discuss the resident visit, any new orders, change in plan of care, and answer any questions or concerns. This also facilitates showing coordination in care.

23. Hospice Home Health Aide Requirements • Hospice Requirements • Long-Term Care Requirements

24. Orientation

25. Facility Staff Needs to Know • What is in the contract • Hospice Philosophy • Who to call when • When will hospice staff visit • How are “standing orders” managed • How the facility staff input is included in the Hospice IDG meeting

26. Hospice Staff Need to Know • What is in the contract • Facility layout • Facility chain of command • Nursing Home Federal and State regulations • Impact on annual survey

27. Hospice Staff Needs to Know, Continued • Where to document in the chart • When and where are the resident care conferences held

28. Change in Status • Hospice and NH staff must derive resident care decisions from the same core data • Rehabilitation/curative vs. palliative • Further changes anticipated – team review • Change related to progression of terminal illness? • Was the change already anticipated and documented on MDS?

29. “In an end-stage disease status, a full reassessment is optional, depending on a clinical determination of whether the resident would benefit from it. The facility is still responsible for providing necessary care and services to assist the resident to achieve his/her highest practicable well being. However, provided that the facility identifies and responds to problems and needs associated with the terminal condition, a comprehensive re-assessment is not necessarily indicated.” --Source: Federal RAI manual, page 2-11

30. Need to know……….

31. Hospice Jargon • Pre-Active • Actively Dying • Comfort Packs • Bereavement • LCD, LMRP, NHO Guidelines

32. Level of Coverage Determination

33. Questions and Answers

34. Resources • Michigan Hospice and Palliative Care WWW.MIHOSPICE.ORG • Ethics Committee • Your local Hospice provider • www.growthhouse.org • www.lastacts.org • www.capc.org

35. Resources • www.TNEEL.org • www.elnec.org • Means to a Better End A Report on Dying in America Today (Last Acts, November 2002) • Level of Coverage Determination (LCD)

36. The End