Working Better Together – Hospice & Nursing Homes Jeff Baker, RN, CHPN,

Susquehanna Health Home Care & HospiceBobbie Woolcock, BSN, RN, CNDLTC,

Muncy Valley Hospital Skilled Nursing UnitMay 19, 2011

Background Information

•Muncy Valley Skilled Nursing Facility

•SNU 138 beds•Attached to 20 bed Critical Access Hospital •Rural community of Muncy•Promotes admissions of clinically complex residents;

–Chronic Ventilator dependent–Wound Care–Rehabilitation–Dementia (12 Bed Dementia Unit)

Background Information

•Susquehanna Health Home Care & Hospice

•Average Daily Census 700 +–Hospice Average Daily Census 90-100 –Providing Hospice Services for 28 years

• Inpatient Unit – Gatehouse- 7 beds, opened 2006• Two full-time Hospice & Palliative Care Certified Physicians • All Professional Staff are certified in Hospice & Palliative Care

Susquehanna Health Home Care & Hospice

Coverage area

Why nursing homes?•20% of Americans die in nursing homes•Projected 40% in 2020•50% of nursing home residents suffer from untreated pain.

CAPC 2008JAMDA 2010

Learning the Culture•Who is the gatekeeper?•What is the approach to end of life care?•Importance of administrative and medical staff support•Importance of each member of the nursing home team

Benefits of Hospice in the Nursing Home Environment

•Hospice improves quality of care for hospice enrollees•Better care for nonhospice residents by diffusion effort•Focus on pain and symptom management•Additional support (family, spiritual, bereavement)

Regulations•Nursing Facility Regulations:

• Long term care is the most regulated industry in the country• A deficiency in state survey can derail the palliative care initiative• Visit to the State Department of Health• DEA prescription regulations• Communicate with consultant pharmacists

•Hospice Regulations• Joint Care Planning• Hospice oversees End-of-Life Care• Nursing Home Services must be consistent with Hospice care

provided in the home• Active involvement in care conferences• Contract for services

Hospice Growth in Nursing Homes

0

100

200

300

400

500

600

700

2005 2006 2007 2008 2009 2010

Hospice referrals

Palliative Care in Nursing Homes Growth

0

200

400

600

800

1000

1200

2007 2008 2009 2010

Other SNUMV SNU

SNF Admission Activity

0

40

80

120

160

200

2007 2008 2009 2010

Defining Roles•Nursing Home

Nursing CNA’s Social Service

•HospiceNursingHome Health AideSocial ServiceChaplainVolunteers

•Key Players Medical Directors Advanced Practice Nurse Palliative Care Team

Assessing the Residents for Hospice

•Interdisciplinary Team Discussion•Palliative care involvement•Family discussions•Physician involvement for hospice

•Hospice initiates care plan in conjunction with Social Service.•Any disciplinary adds specifics to care plan. •Plan of care reflects participation of hospice, facility and residents or representative per F-Tag 309.•Hospice and facility communicate when any changes are indicated to the plan of care per F-Tag 309.•Care Plan Example:

–PROBLEM Hospice/End of Life Care –RELATED TO Failure to Thrive ; Family's desire to maximize comfort; and for support of Husband, and children.–TARGET DATE On-going –NURSING---- Meds, as ordered ; Keep children and Spouse apprised of changes in her condition or treatment; –HOSPICE STAFF---- RN visit 1x/week for pain and symp. management –HOSPICE STAFF---- CNA 2x/week afternoon program –HOSPICE STAFF---- Chaplain for spiritual support –HOSPICE STAFF---- MSW for emotional support –ALL STAFF---- Offer food and drink as resident will accept. Address w/calm voice and gentle touch/stroking ; Reposition, as needed, for comfort (in her bed, as well as w/c); Assure desired room temp (offer blanket when in w/c, as Snow White often feels chilly); Family support, reassurance, education, as needed. Advise nursing of s/sx of discomfort not relieved by non-pharmaceutical interventions. Consult social services prn. Continue to assist Spouse, Prince Charming, to be near. He likes to sometimes hold her hand when they sit side by side in Sunroom, or when she is in bed.

•Future plan – continue to fine tune process for individualized plan of care.

Joint Care Planning

Building Relationships•Common goals•Project groups•Visibility•Education = Learn together•Interaction•Eating Lunch together

Education Physician education

prognosis, appropriate referrals Staff education

ELNEC, ELENA, CEUs Patient and family education All unfamiliar with the differences between hospice and palliative care Staff education and hospice use intensity may contribute to nursing homes’ performance in EOL care JAMDA 2010

Medication Management•Pain and symptom management•Documentation to support medication orders outside Long Term Care recommendations.•Includes directives for managing pain and other uncomfortable symptoms per F-Tag 309

~ American Data Product

ECS, as it is referred to, is our Electronic Charting System Muncy Valley Skilled Nursing Unit initiated it’s use in July of 2007ECS has many capabilities:

• CNA Picture Charting• Physician’s Order Entry• E-MAR/TAR• Licensed Nurse Charting• Other Department

Documentationa. Therapy (PT/OT/ST)b. Activities c. Social Servicesd. Dietary

MDS 3.0/Roster/Census and ConditionCare PlansReportsTime Clock

~ EncoreAutomated plan of treatmentProblem-based care plansEasy access to patient informationAutomated visit entryBereavement risk assessmentSpiritual assessmentPhysician documentationIDT review and documentation

~ Future PlansInterface capabilities

Information TechnologyMaking the system work

Communicating Value•Resident satisfaction •Outcome measures

Interface with Palliative Care

•Palliative care census in LTC•Addressing symptoms•The hospice discussion

Special Programs•Last Moments

~ Bedside vigil provided for resident at end of life~ No patient dies alone.~ Coordinated with resident, family and nursing home

staff~ Primary nurse assesses hours needed. ~ Utilize trained volunteers, home health aides, social

workers, professional staff.~ Few hours to 24 hour coverage depending on resident

needs.~ Communicate schedule to nursing home to assure

coverage~ Music therapy~ Massage Therapy

•Whispers of Peace– Hospitality Cart for families with mini fridge stocked with food and

beverages 2X per shift – Memory Journals or cards from staff to families– Communication to families and community via newsletter and

newspaper

Bereavement•Resident’s family ( including staff as family)•Discharge calls•Monthly Memorial Service•Heartworks

Case Studies

Questions?

Contact InformationBobbie Woolcock, BSN, RN, CNDLTC, Muncy Valley Hospital Skilled Nursing UnitMuncy Valley Hospital 215 East Water StreetMuncy, PA 17756(570) 546-4040800-488-4268bwoolcock@susquehannahealth.org

Ann Packer, BSN, RN,Hospice ManagerSusquehanna Home Care & Hospiceapacker@susquehannahealth.org1-800-320-7691