Evercare Quality Improvement Awards

1. Evercare Quality Improvement Awards James Collins, M.D. Julie Hayes, R.N. Randy Muenzner

2. Faculty Disclosures: Dr. Collins Medical Director, Evercare Pfizer Pharmaceuticals: Speakers Bureau Eisai Pharmaceuticals: Speakers Bureau

3. Learning Objectives By the end of the session, participants will be able to: • Understand the need for improved End of Life practices in Long Term Care Facilities • Identify barriers to End of Life Care • Identify end stage disease indicators • Understand how the Modified Flacker Mortality tool can be incorporated into existing facility practices

4. Facility Demographics • Elderwood Healthcare at Maplewood • Cheektowaga, NY • 160 Beds (138 long term/22 subacute) • Private Owner

5. Palliative Care Process Improvement • Problem • Recognition of terminal status for residents with chronic illness occurring late in disease process. • Little or no time for families/residents to make informed decisions. • Little or no time for staff to plan or implement quality palliative interventions. • Poor outcomes.

6. Modified Flacker Mortality Scale • Objectives • Provide nurses/physicians with an accurate, objective tool to monitor progression of disease process. • Provide nurses/physicians and families with time to review resident’s status, advanced directives and options for treatment.

7. End Stage Disease Indicators • Resident characteristics assessed on Flacker Mortality Scale: - Functional ability (ADL Score) - Weight Loss - Shortness of Breath -*Swallowing Problems - Sex (Male at higher risk) - CHF - Age * Found in our study to be an early sign of decline.

8. Project Timeline • Study began October 2005 • Funded by Community Health Foundation as a collaborative endeavor with Hospice of WNY and Elderwood Healthcare at Maplewood. • Began on one unit with 40 residents • Flacker Tool • Later modified to exclude residents with advance directives for aggressive care. Subsequently identified as the Modified Flacker Tool. • Study ended December 2006 -Completion of Modified Flacker assessments to all long term care residents. • January 2008 • Policy was implemented in all Elderwood Senior Care facilities covering over 1300 LTC residents.

9. QI Planning & Implementation • Leadership • Dr. James Collins, Medical Director • Julie Hayes, Assistant Director of Nursing • Informal weekly meetings from 10/05 to 12/06 • Facility wide implementation 1/07 • (4) Unit Managers • MDS Coordinators • 30 minutes weekly per nurse manager • Communication • Informal introduction to interdisciplinary staff over a period of time.

10. Modified Flacker Assessment • How was study conducted? - Formatted Modified Flacker tool into User Defined Assessment Software. • Issues encountered & how they were overcome - Staff resistant to change. Residents identified by the tool didn’t look like the type of End of Life Resident with whom staff were familiar.

11. Tools Used to Affect Change • Tools used • Information obtained from last MDS completed. • Assessment schedule follows MDS cycle. • Tools created • Modified Flacker Form

12. Facility Expenses • No significant expenses incurred. • After initial education and implementation individual nursing time to complete weekly assessments is approximately 15 minutes. • No additional staff needed.

13. Outcomes • Resident Outcomes • Facilitates residents to prioritize needs and wishes. • Advanced directives established. • Resident & family directed plans of care. • Residents & family emotionally prepared. • Regulatory Outcomes • Care plans are accurately prioritized.

14. Outcomes • Improved Quality of Service • Priority is determined by the resident’s preferences with proper education of possible outcomes. • More effective Pain Management. • Proactive Advance Care Planning eliminates futile and inappropriate treatments. • Spiritual and Emotional needs of both resident and families are identified and addressed by the interdisciplinary team including the Chaplain.

15. Outcomes • Enhance Staff Performance • Early identification of the terminally ill resident enables staff to gain more insight into the special needs of the resident and family. • Improved quality of life at the end of life has enhanced job satisfaction. • Effect on Staff’s “every day” routine work • Created a culture within the building to allow for all involved to be comfortable with the dying process.

16. Outcomes • Improved organization & management structure & systems • Modified Flacker Tool is completed at the same time an MDS is completed. Staff member experiences no additional work load. • Clear and timely approach to establishing a Palliative Plan of Care. • When implementing you are only establishing a measurement tool to identify when a Palliative Plan of Care should be activated. • No change in current Palliative Plan of Care nor staffing needs.

17. Outcomes • Financial Outcomes • Revenue neutral for the facility. • Cost savings to the health care industry by reduction in unwanted hospitalizations.

18. Closing Thoughts • What is the feasibility that this project could be implemented at other facilities? • Feasibility is simple. Has been implemented in 9 more facilities. • Lessons Learned • How easily culture change occurred when this process was implemented. There was “buy in” from staff, residents and families. • Helpful Tips/Insights • One individual can impact an entire facility when they bring forth an idea whose time is come. • Any Questions?