Handout Template 2017 - Hospice Fundamentals

www.hospicefundamentals.com Hospice Fundamentals Subscriber WebinarDecember 2017

© 2017 Hospice FundamentalsAll Rights Reserved 1

The Clinician’s Connection Care Planning: Problems, Goals

and Interventions

December 2017 Subscriber Webinar

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Today’s Session

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• What the Medicare regulations require for care planning

• Establishing rules and standards for care planning

• Individualizing plans of care, focusing on patient / family needs

– Identification of problems and interventions

–Making goals measurable

1. Care is focused on palliation rather than a cure

2. The unit of care is the patient and the family

3. Care is provided by interdisciplinary team

4. Care continues through the bereavement period

What Distinguishes Hospice Care?



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What do we promise people who are dying and those around them when we tell them about hospice care?

What Do the CoPs Actually Say?

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The Condition and the 5 Standards

§418.56 IDG, Care Planning & Coordination of Services

§418.56 (a) Approach to Service Delivery

§418.56 (b) Plan of Care

§418.56 (c) Content of the Plan of Care

§418.56 (d) Review of the Plan of Care

§418.56 (e) Coordination of Services



Problematic Care Plan Items

Order Cited

L Tag Section Regulation

1 L543 §418.56(b) Standard: Plan of care

2 L545 §418.56(c) Standard: Content of the plan of care

6 L547 §418.56(c)(2) Standard: Content of the plan of care

8 L555 §418.56(e)(2) Ensure that the care and services are provided in accordance with the plan of care

From CMS Top 10 Survey Deficiencies List 20167

Think of the Plan of Care as a Road Map

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Problem Where do we want to go?

Measurable Goal Who will we know when we get there?

Interventions What route will we take to reach the destination

Evaluating How will we know if we are still on the best route?

Updating of Goals What if we decide to change the destination?

Coordination How will we communicate along the way?

Common Problems & IssuesQuality Survey Payment

Not individualized X X X

Not updated as care needs change X X X

Not established at the right time X X X

Not reviewed by IDT at appropriate intervals X X X

Indicated interventions not provided during visit X X X

Lack of involvement by entire IDT and attending X X X

Goals not measurable, not patient centered X X X

Eligibility disconnect from POC X X X

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Contents of Plan of CareA plan of care is a roadmap or GPS and includes

• Problems or needs– As identified in the initial and comprehensive assessments

• Measureable Goals– How hospice knows if the care is making a difference

• Interventions– What is going to occur

– Who is going to provide the care

– Frequency of services, visits

– Medications, DME, supplies

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The Cycle of Care

IDT Assesses

Identifies Problems/ Needs

Creates Plan of Care

Delivers Services

Evaluates Outcomes

Plan of Care – Critical Elements

Established – before services are provided

– by IDT in collaboration with attending physician

– based on patient specific assessments of needs including management of pain and symptoms

Is updated as frequently as patients condition requires but at least every 15 days

Notes progress or lack of progress towards the goals

Includes scope and frequency of services

Care and services must be consistent with plan of care

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Universal Care Planning Events

1. Opening or initiating a plan of care

2. Updating a plan of care

3. Closing a plan of care

But before you start…

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Before You Start…

How many goals are needed?

When do you care plan and when don’t you?

Do you have to care plan Nursing 101 material?

How to assure that it is patient/family focused?

How will IDT communicate?

What are the components of your plan of care?

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Individualized Plan of Care

•Patient/ family input & goals of care

•IDG comprehensive assessment(s)

•Physician orders

•Medication Profile

•HA assignment

•Volunteer assignment

•IDG discussions



Focus of the Plan of Care

Who is really in charge?

The patient and family!

Care Planning’s Big Three

1. Identifying Problems

2. Setting Goals

3. Planning Interventions

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Patient/Family Problems/Needs

Identified in initial and ongoing assessments

Findings of all assessments are directly tied to the care planning process

Whose problem is it anyway?

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A Word About Goals

• Goals‐patient and family directed

• Measurable

• Not static ‐ must be flexible and will change as the situation requires or patient declines

• Should be reviewed any time there is a significant change in status

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What Do People Want?

1. Adequate pain/symptom control

2. Avoiding inappropriate prolongation of dying

3. Achieving sense of control

4. Relieving burden

5. Strengthening relationships with loved ones

Singer, et. al., Quality End‐of‐Life Care ‐ Patients’ Perspectives,

JAMA, 1999; 281:163‐168 (Jan 14)

Meeting Patients Where They Are

Experts have concluded that if a patient is given an opportunity to speak without interruption for 2 minutes at the beginning of an encounter, the patient will provide the health professional with his or her issues and goals.

Talking with Patients (Vols 1 and 2), Cassell, E

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Establishing Patient Goals

What does the patient want?

Don’t ask “what are your goals” since they may not know how to define goals

Instead ask “What is important to you now?”

“What are your needs today?”

“What would you like to get accomplished over the next couple of weeks?”

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Goals of Care

Hopes, goals, expectations change with illness –May be multiple goals that apply at the same time

– Goals may be contradictory

– Certain goals may take priority over other

IDG’s Role– Clarify goals, treatment plan keeping in mind what is important to patients and families

– Be able to set limits on unreasonable goals

– Incorporate goals into the plan of care

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The Interventions - Achieving the Goals

All services necessary for the palliation and management of the terminal illness and related conditions

– Scope, frequency and responsibility

– Assessments

– Visit frequencies

– Education

– Medications, supplies, DME

– Level of care

What about proactive interventions?

Define what functions you will perform during each visit and what you will document

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The Interventions - Achieving the Goals

The Goal: “ I would like my hair done every Wednesday.”

What interventions are necessary to meet the goal and which discipline will be responsible for each?

Managing pain and symptoms

Transportation to the beauty shop

ADL support

Safety needs

What else?

How does the POC change when she can no longer leave the house?

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The Evaluation

How we know if the care is making a difference?

Is the POC working? If not, what are we going to do to correct this?

Have the problems been resolved?

Are there new problems/issues/needs that need to be care planned?

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The Evaluation

It’s about the outcomes – the progress of lack of progress towards the goals

Stop and think about what are some indicators of your hospice’s effectiveness of the care planning process?

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Back to the Universal Events

1. Opening or initiating a plan of care

2. Updating a plan of care

3. Closing a plan of care

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Opening/Initiating the Plan of Care

How does information from the initial and comprehensive assessments flow to the plan of care?

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Policy: Does policy incorporate requirements from §418.56?

Process– Is the IDT involved in the development? – How is it documented? – Does POC identify care and services to address the immediate needs of the patient and

family as identified in the initial assessment?– How does collaboration with the attending physician (if there is one) occur? – How many goals are expected?

Standards

– What are your hospice’s expectations and standards?

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Collaboration

• Attending physician involvement

• Burdensome process to show IDT collaboration at IDT meetings (sign in sheets, sign each POC)

• Collaboration in updates outside of IDT meeting

• The whole team is involved with plan of care discussions

– Each has a distinctive helpful perspective and expertise to accomplish this fundamental hospice function

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Are the goals measurable? Patient centered? – How can you make goals measurable?

– Is the measurement in the goal?

– Are the goals achievable? Realistic?

Are the interventions directly related to goal achievement?

How is care tied to making progress towards goals?

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Updating the Plan of Care

Are problems identified in the comprehensive assessment and updates care planned?

• What gets on the POC?

• Can you customize if canned problems do not clearly identify the problem?

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Care and services consistent with the POC– Do staff review plan of care before, during and after the visit?

– Is the plan of care guiding the visit – like a roadmap?

– Do you use the power of your EMR to match plans of care to visits made?

– Is each and every visit documented timely?

– Do you review POC during IDT?

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The EMR

Do you clearly understand how to use your EMR in care planning and visit documentation?

How much flexibility do you have in individualizing POC? Problems? Goals? Interventions?

What is the process for staff to learn how to individualize the POC?

Do you use set POC templates? How are they working? How can they be improved?

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What is considered a significant change in patient’s condition triggering a revision?

– How does this get communicated to the IDT?

– How is the IDT involvement get documented?

How does communication with the attending physician occur?

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Closing a Problem

Is the POC reviewed at IDT meetings and changes made at the review?

What triggers closing a problem on the plan of care? Goal achievement? What else?

How does it work in the EMR?

Who can close a problem on the plan of care?

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All Should Be Addressed in the POC

• FAST, PPS

• Weight loss/decline in MAC/BMI

• Increasing dependence in ADLs

• Dysphagia

• Pocketing food

• Incontinence

• Skin breakdown

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• Agitation

• Increased periods of sleeping

• Immobility

• Infections

• Medication changes



Plans of Care

• Should change with decline

• Support eligibility

• Services provided according to plan of care

• Examples

– Hospice aide increased from 3 times per week to daily as wife can no longer manage the increased physical requirements

– Example: Hospice aide assignment changed to bed bath as too difficult to transfer patient into shower

– Example: Oxygen order for 3 liters continuous from PRN

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Hospice Compare and Care Planning

How does the effectiveness of your hospice’s Care Planning impact your Hospice Compare scores?

1. Identifying Problems

2. Setting Goals

3. Planning Interventions

Actions of the Prudent Hospice™

DefinePolicy

Process

Standards

Educate

Deliver



Two Critical Factors for Success

Discipline Discipline Specific Hospice Skills

This Is How We Do It Here


SuccessSuccess


Functioning as an IDT Member

EMR & Documentation

AssessmentIdentification of

Problems

Establishment of Measurable

Goals

Planning Interventions

Delivering Care

Updating Care Plan

Actions of the Prudent Hospice™

• Utilize the Universal Care Planning Events and questions to guide your process improvement

• Hold staff accountable to “This is the Way We Do It Here” for care planning

• Ensure all staff understand how eligibility ties to the plan of care

©2017 All Rights Reserved - R&C Healthcare Solutions & Hospice Fundamentals 45



To Contact UsSusan Balfour919‐491‐0699

[email protected]

Roseanne Berry480‐650‐5604

[email protected]

Charlene Ross602‐740‐0783

[email protected] information enclosed was current at the time it was presented. This presentation is intended to serve as a tool to assist providers and is not intended to grant rights or impose obligations.

Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.

December 2017 Subscriber Webinar 1 © 2017 All Rights Reserved Hospice Fundamentals

Case Example: Mr. Jones 78 year old admitted with ASHD. Depressed and anxious because of disease. Comprehensive assessment indicates

1. Pain – 6 /10 using verbal pain scale. Angina with exertion and occasionally at rest. Pain is more frequent and now greatly restricting any activities he found pleasure in doing.

2. Shortness of breath with any activity. Use of accessory muscles. Treatments consist of use of MS, oxygen and nebulizers, but he frequently takes off his oxygen.

3. On PRN opioid with bowel regimen started on admission. 4. Gait increasingly unsteady – holds on to walls and chairs with ambulation – won’t use a

walker 5. Mr. Jones 6. Confirmed still does not have an Advance Directive, but considering it 7. Ambivalent about future hospitalizations as he has always gotten better before 8. Patient and caregiver refused to discuss any spiritual / existential concerns, but willing to

see the spiritual counselor

Problems / Issues/ Needs: Pain management / Control Goal: Patient’s goal is pain to be controlled at a level of 3 or better Interventions:

• Added Nitrates for symptom relief

• MS 5 – 10 mg q1h prn pain / dyspnea

• Education related to use of pain medications and side effects

• Assessment of pain level by all disciplines every visit using the verbal scale & CM notified if greater than 3

• SN frequency – 3 x week for 1st week then reevaluate

IDT update: Pain continues to be at a level of 5 – 6 as doesn’t like feeling he gets with the MS. Nitro gives him a headache. Educated on use of O2 with any activity. Changed to long acting MS for better pain management and control. SN frequency – 4x week until pain better managed to ensure using medications appropriately.

Problems / Issues/ Needs: Dyspnea with activity Goal: Patient’s goal is dyspnea to be controlled to a mild level Interventions:

• Increased O2 to 3 – 4 liters

• Evaluate effectiveness of nebulizers

• Encouraged to wear O2 at all times and especially with any activity

• Teach energy conservation techniques

• Assessment of dyspnea by all disciplines every visit using a verbal scale of mild, moderate, distressing & notify CM if greater than mild

IDT update: Dyspnea continues at a moderate level, especially with ADLs. Continue to encourage him to use O2. Has agreed to help and HA schedule 3 times/ week to assist with ADLs


Problems / Issues/ Needs: At risk for falls due to unsteady gait Goal: Patient to remain safe with activity Interventions:

• Walk through of house to identify fall risks

• Educate on all risks and how to minimize

• Evaluate placement of O2 tubing

• Instruct to take diuretics in morning when patient most alert

• Encourage to use assistive devices

• Continue to education on how to sue assistive devices properly

IDT update: Has had no falls. Beginning to use walker more when out of the house, but still uses walls and chairs while inside. Continue to reinforce use of walker. Provide BSC for when needs to get up at night for the bathroom

Problems/Issues/Needs: No advance directive but requests additional information. Not sure about future hospitalizations Goal: Advance directive discussions and information will be provided by December 20th Interventions:

• SW & RN to educate and assist with advance directives

• SW to encourage family meeting to discuss advance directive

• IDT to explore the benefits of DNR status with patients and families and any future hospitalizations

• SW encourage execution of advance directives while patient is able

• SW frequencies – 1 x week until family decision made IDT Update: Family meeting held on December 15th . Family in agreement with patient wishes. Advance directive being completed by patient. Pt express desire to not return to hospital. Will make a follow up visit by December 20 to obtain copy of completed advance directive. SW frequency changed to 2 x month

Problems/Issues/Needs: Religious/Spiritual Struggle Goal: Patient will report feeling less spiritual struggle during next 2 spiritual counselor visits Interventions

• Spiritual counselor provide pastoral dialogue

• Spiritual counselor provide reflective conversation

• Spiritual counselor provide spiritual reflection

• Spiritual counselor facilitate faith expressions

• Spiritual counselor to provide dialogue to facilitate examination of beliefs

• Spiritual counselor frequencies – 2x week IDT Update: Patient seems less anxious partly as consequence to experiencing forgiveness. Continue with current interventions. Spiritual counselor frequencies change to 1 x week.


Case Example: Mrs. Hernandez Mrs. Hernandez is a 98-year-old female with advanced Alzheimer’s.

1. Incontinent of bowel and bladder 2. Has no memory and says over and over again “You are hurting me” even when no one is

touching her 3. Needs assist in all ADLs and can no longer feed herself 4. Some dysphagia and pocketing of food 5. Unable to ambulate at all; daughter places her in a recliner 6. Recent hospitalization with aspiration pneumonia and stage III decubitus to the coccyx 7. Weighs 99 lbs. with a BMI of 19 8. Cries with any movement and dressing changes to the decubitus 9. Lives with daughter and her spouse

What might the care plan look like?

Problems/Issues/Needs: Pain Control Goal: Pain will be managed at caregiver defined acceptable pain level of 3 or less on PainAd. Interventions:

• Assess pain each visit by each discipline - Notify CM if pain greater than 3 on PainAd

• SN to assess the effectiveness of pain medications and use of breakthrough

• SN to educate CG on use of medication and positioning

• Assess constipation related to increase in opioid use

• Medications (whatever is in the orders/ medication profile-does not need to be repeated)

IDT update: Pain has been above 3 several times in past week as CG is not providing medication before wound care as ordered. Will provide further education and increase RN visits to 4 times a week (every other day) for reinforcement. Will reassess effectiveness of medication regimen.

Problems/Issues/Needs: Daughter concerned about ability to continue to care for patient at home. Goal: Develop a plan by December 15 to meet needs of patient and daughter as condition continues to deteriorate Interventions:

• Increase hospice aide visits to daily to provide for ADLs

• SN assess ADL decline in patient

• SN obtain Hoyer lift and geri-chair

• SN educate on transfer techniques

• Volunteer to come weekly, sit with patient so daughter can go out and get hair done & run errands

• SW explore financial resources for hired caregiver

• SW assist with Medicaid application for aide and attendant care

• SW to explore if alternate living arrangements would be acceptable (ALF, NH)


IDT Update: Daily HA visits lessened daughter’s fatigue. Volunteer will now come 2 times per week to allow daughter more time for herself. New DME in home and daughter and son-in-law have been educated. SW to complete a financial assessment next week.

Problems/Issues/Needs: Skin Integrity Goal: Wound free of infection Interventions:

• SN provide education to CG on best skin care practices per protocol

• SN provide and instruct on use of adult briefs

• SN evaluate discuss with caregiver of pros and cons on use of Foley

• SN evaluate effectiveness of wound care

• SN teach caregiver dressing changes

• SN evaluate caregiver’s ability for dressing changes

• SN provide wound care per orders IDG Update: Daughter prefers to use adult briefs and avoid use of Foley at this time. Wound remains free of infection. Continue wound care per orders

Documents

Handout Template 2017 - Hospice Fundamentals