Today’s Webinar will begin at 11:30AM

6/27/12

Introduction

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Peg Nelson, NP, ACHPNachpnDirector of Palliative and Pain Services

St. Joseph Mercy Oakland

Our Palliative Care Joint Commission Journey

Peg Nelson, NP, ACHPN

Director Pain and Palliative Care Services

The Journey of Creating Peace and Healing at SJMO

Began in late 1990s when we were attempting resuscitation on 60-70% of the patients who died

Only could find 30% patients with any pain scores at all documented

Of those we could find – average pain score when palliative care was consulted: 8/10.

Demerol was number one drug used for pain

First Work

Understanding the suffering at SJMO Learning from hospice, ethics and local palliative

programs Institute of Medicine (IOM) Report on End of Life Institute of Healthcare Improvement SUPPORT Trial

Mercy Supportive Careest. 1999

MSN and oncologist Harpist Healing touch practitioner Lots of nurses, case managers and an administration

who supported palliative care and pain management

Key Processes to Achieve Goal

Assess and understand the suffering. Educate, develop and inspire staff and

volunteers to deliver excellence in pain and symptom management, ethics, palliative and end of life care management.

Create systems of care across the continuum that make it easier to deliver quality care and support staff and volunteers who deliver care.

Create access for all who are suffering.

TOTAL BODY MODEL FOR SUCCESSFUL PALLIATIVE SERVICES at SJMO*

Head: Knowledge, Competence

*Conscience:“Know what to do and the right thing to do”

Hands:Process, Systems

*Culture:“How to do it

so all are served”

Heart:Compassion, Humanity

*Presence:“Doing it withenduring love”

Trinity Health Vision for Palliative Care

In Trinity Health everyone impacted by illness will have access to comprehensive palliative care and experience

care excellence through the prevention and relief of physical, emotional, social and spiritual suffering.

Compassionate and holistic care will be provided throughout the journey of living and dying.

We Studied Our Own Experience

Through family post-death interviews Staff assessment of the patient and family dying

experience and their own suffering and needs Post-death chart review

Our Response

Created a new culture, where suffering is not acceptable with focus on continuous improvements in patient care.

Provide 24-hour pain, palliative and spiritual support for patients and their families.

Provide team members (staff and volunteers) with the training and tools necessary to provide excellence in end of life care.

Multiple entry points for receiving pain and/or palliative and/or hospice care.

Interventions

Required 5 hour pain/palliative class Extensive resident and nurse end of life education Comfort Care order sets Mentoring staff One patient at a time – the world and culture changed

Pain Scores

At time of consult for palliative care:2000 – 7.8/102001 – 6.3/102004 – 3.4/102005 – 2.4/10….and continues to this day

Which was one of the biggest reasons we won the

Circle of Life Award in 2006

COMFORT CARTS“Crash Carts for the Dying”

• CD Player and many CD’s• Bibles, Korans• Example of Prayers• Grief Information• Funeral Home Listings• Information on physical,

emotional and spiritual changes at end of life

• Sympathy cards/Dove Sign for Door

• Hand Casting Materials• Love Blankets

“This is a love blanket, it is a symbol of the love shared in ____’s life.

We hope it brings him comfort now and after he dies please take it with you and may it help you in

the days to come.”

Creation of a loving and peaceful environment – we call sacred space

Early Milestones

CALL CARE Project – Supportive Care of the Dying Coalition – one of 11 sites in 2001 funded by Robert Wood Johnson – to implement palliative outpatient services

$150,000 donation from family of patient to expand services - 2002

$200,000 Trinity Health Mission grant to expand palliative care services for the poor in Pontiac 2005

Comfort Companions

Common top two fears people have at end of life are: Pain not being controlled Dying alone

Our Comfort Companion Program helps to ease these fears by:

Providing a loving presence for patients. Providing support and respite for families. Assurance that patients are safe from distressing

symptoms.

Comfort Companions Bring:

Presence Kindness Assurance of physical and

emotional comfort Notifies staff if needs arise Communicates with

family Soothing Environment Sensitivity to culture and

spiritual needs Love

Since 2005, 468 patients served, and over 9824 hours of service

Bedside Sacred Ritual in Ambulatory Surgery

Life in the Emergency Department and death

Palliative Care Team

NP Director* Medical Director* Bereavement/Volunteer

Coordinator Nurse Practitioners* Music

Practitioner/Harpist Healing Touch/Massage

Therapist

Chaplain Respiratory Therapist Case Manager Dietician Pharmacy Wound/Ostomy Nurse Utilization Review Homecare/Hospice Oncology Nurse Social Work Internal Medicine*Palliative Board Certified

We aspire to meet the National Consensus Project’s clinical guidelines for quality

palliative care.And use CAPC tools and consensus

recommendations

8 Domains of Quality Palliative Care

1. Processes and Structure of Care

2. Physical Aspects of Care

3. Psychological and Psychiatric Aspects of Care

4. Social Aspects of Care

5. Spiritual, Religious and Existential Aspects

6. Cultural Aspects of Care

7. Care of the Imminently Dying

8. Ethical and Legal Aspects of Care

We are seen as the pain and palliative care team

Reason for consultation: 40% physical and psychological symptom

management 40% Clarification of goals, advance care planning,

family support and communication 20% End of life, withdrawal of life support and

transition to hospice

Practical Aspects

Scattered-bed Consultation Service (Oncology/palliative unit sees most expected end of life)

24/7 with weekly team meetings Typical Social Worker role is shared by Unit

based case manager, social work, unit RN and palliative clinicians.

Oversight by Pain Steering committee which reports to Medical Staff Quality and the Quality and Safety Board of Directors

Palliative Care Snapshot(one month – 31 patients)

Primary Diagnosis

Cancer – 38%Heart Disease – 19%Respiratory – 16%CVI – 10%Kidney – 6%HIV/sepsis/other – 11%

Disposition

34% hospice19% home15% ECF3% rehab29% died

Palliative Care Snapshot(one month – 31 patients)

ICU LOS – 22% (median 3 days, only 1/31 had LOS >7 days)

Hospital LOS – range 2-61, median 7 days LOS on service – range 1-36, median 4 days Race 83% White, 13% Black, 4% Hispanic

Palliative Care Service

Palliative census – range 2 to 10 per day (average 5) (NP bills 110-190 visits/month), average 32 palliative consults/month

Referrals for bereavement support, comfort massage, No one dies alone support, life review assistance, chaplain and healing touch can be ordered by RN

Consultation for goal clarification and/or symptom management ordered by physician

Of Patients who died

All died in private room One patient died alone Pain score before death – average <1/10

Range 0-3/10 No patients had CPR at death

Expense/Cost Avoidance/Revenue

Total Expense $540,000/year FTE’s 4.8 Cost Avoidance based on CAPC impact calculator –

$920,000* (based on volume we are more productive than most mature programs)

Revenue NP billing: $230,000 - $99,000 = $131,000 Donations: $11,390

Current Performance Measures

Spiritual Assessment (Process and Outcome) Non-pain symptom assessment (Process) Pain reduced to 4/10 or acceptable level in 24 hours

(Outcome) Family was given appropriate information in order

to make decisions regarding loved one (Outcome) (Previous outcome for family – felt patient died

comfortably and felt supported)

Quality Metrics

010203040506070

8090

100

June Sept Nov 12-Mar

Nonpain

Spirituality

Pain <4

Commitment to Support of Others – since 2005 we have mentored:

131 Hospitals, ECFs, hospices and corporate/health systems

64 individual Clinicians 81 new No One Dies alone programs >2200 clinicians attended pain/palliative classes 30 churches and over 300 parish nurses 9 Colleges/Universities

Keys to Successful Certification

• Mature Palliative Care Program• Experienced Clinical

Leader/Director• Experienced Medical Director• Senior Leadership Support• Certification in Palliative Care –

hospital priority

Documents Prepared

• Developed written ‘Scope of Practice’• Performance Improvement Plan –

formalized in 2011 • Performance Measures Submitted• Education binders based on domains• Team orientation manuals• End of Life/Bereavement Policy

Lessons Learned

• Rehearse Tracers/Mock surveys were helpful• Speak as an interdisciplinary team, the

survey will be team focused• Prepare and demonstrate 4 months of data

for review at survey• Focus on National Consensus Guidelines,

CAPC, or National Patient Safety Foundation• Utilize published tools and resources• Imperative to disseminate educational

materials

Lessons Learned

• Role of chaplain and social worker• Performed detailed tracers on

patients• Job descriptions for practitioners• Scope of practice shared among

members• Non-pain assessments and

documentation of assessment

Resources

• The Joint Commission Disease Specific Certification Guide

http://www.jcrinc.com/Accreditation-Manuals/PCC12/4032/

• Center to Advance Palliative Carehttp://www.capc.org/about-capc • National Consensus Projecthttp://www.nationalconsensusproject.org/ 

Resources

Center to Advance Palliative Care Palliative Care Consultation Service Metrics:

Consensus Recommendationshttp://online.liebertpub.com/doi/pdfplus/

10.1089/jpm.2008.0178 CAPC Certification Guidehttp://www.capc.org/palliative-care-

professional-development/Licensing/joint-commission/tjc-guide-2011.pdf

Resources

The Joint Commission (TJC) Advanced Certification for Palliative Care Programs

http://www.capc.org/palliative-care-professional-

development/Licensing/joint-commission

Peace and healing is sacred

Contact information:Peg Nelson 248.858.3399nelsonp@trinity-health.org

Notes will be on our website

Thanks for joining us today!