Culture Change in Hospice of the Lakes: Multi-disciplinary to Inter-disciplinary

1. Culture Change in Hospice of the Lakes: Multi-disciplinary to Inter-disciplinary Descriptive Society Annual Meeting September, 2008 Richard Heinrich, M.D., M.A.

2. Why is this topic important? • When Keith asked me what I was working on at first I said I didn’t have anything to present, then after some reflection I thought about what I have been doing for the past 8 years. • I would like your help in telling this story… • You are all resident experts in DP and all have some organizational expertise…. • So in each act what advice would give to the Hospice leadership group?

3. An unfolding story in three acts Multidisciplinary to Interdisciplinary Teams (teaming) Act I: Nurse care manager model Act II: Self managed care teams Act III: Interdisciplinary care teams Act IV: ??Trans-disciplinary or ???

4. Background • Managed care and nursing 1980 to 2000 • Hospice care: In the 1982 Tax Equity and Fiscal Responsibility Act (TEFRA), Congress added a hospice benefit to the Medicare program. • Cost went from $1.2 B in 1995 to $8 B in 2005 • Budget in the foreseeable future will not keep pace with the tsunami of baby boomers, 76 million who will start to come of a certain age in 2011 • New buzz word is “affordable care’

5. What are we doing by doing that….? • Fragmented care as a hallmark of the evolution of the US care delivery non-system based upon individual choice • Disease management as a failure path to controlling costs, may or may not improve quality of care • One approach to fragmentation is the concept of a primary care “home” where primary care is staffed up to provide team based care to address fragmentation • ???? Questionable what outcomes will be achieved • Congress wants value and affordable care • Little political courage in facing the clinical, operational and financial incentives that it would take to provide a STEEEP care delivery system (safe, timely, effective, efficient, equitable and patient/family care delivery system

6. Hospice: a platform to provide comprehensive patient/family centered care • Traditional hospice programs were founded on a nurse case management model • The team concept in hospice is poorly defined

7. Increasing census and requirements Load versus HOL horsepower Hospice of the Lakes “horsepower” hauling the load Year 2005 Year 2001

8. Increasing census and requirements Load versus HOL horsepower Hospice of the Lakes “horsepower” hauling the load Year 2008 Year 2006

14. Three Acts in an unfolding Drama Act I: Traditional Nurse Case Manager Model Act II: Self-managed Teams Act III: Inter-disciplinary Teams Act IV: ??Trans-disciplinary???

15. Act I: Prior to 2003 • Traditional Nurse Case Management Model • Players • Leadership and managers • Nurses • Social Workers • Chaplains • HHA, Volunteers

16. Evaluation, Outcomes and Problems • East and West Side Geographic division of patients • Nurses owned the patient and decided on what services were necessary • Staff centered focus • No specific teams or working relationships • Meetings were chaotic • Little supervision or accountability • Lack of respectful interpersonal relationships • Poor meeting hygiene

17. Advice to the hospice leadership group?

18. Leadership and program changes as the end of Act I • New Leadership group begins in 2000-2001 • I became Medical Director in 2001 • New program director in 2001 • Census was in the 80s, patients were vended, program not serving the HP Medical Group nor patients • HP Pursuing perfection initiative

19. The Pursuing Perfection Project • ICI and the RWJ Foundation sponsored a nationally competitive grant among organizations committed to rapid cycle improvement of their healthcare delivery systems • HealthPartners was one of 7 selected organizations in 2001 to improve their care delivery system. • One of 7 projects at HPMG was to improve the quality of care delivered at end of life

20. Improving Organizational Capacity to provide State of the Art End-of-Life Care

21. Begin with the End in Mind To implement organization-wide, perfectly coordinated, state-of-the-art end-of-life care that addresses pain and suffering!

22. Pursing Perfection: brewing concepts of organizational care and collaboration • Rapid cycle change!!!! • HP organizational map of care and strategy to bring about change • Home based care • Hospital based care • Clinic based care • Skilled nursing home based care • Assisted Living based care

23. Addressing Pain and Suffering at the End of Life State-of-the-art end-of-life care encompasses: • a broad range of clinical practices, • patient and family- focused access to such care • STEEEP principles and • seamless organizational implementation across venues of care.

24. End of life Care Goals of Treatment • Self-determined end of life closure & care • Comfortable dying (effective palliative treatment of symptoms and suffering) • Safe dying • Effective Grieving and coping • NHPCO Goals for Hospice Organizations

25. Promises to Patients and Families regarding End-of-Life Care • You will know that 100% of HOL staff, HPMG & Clinics and Hospital staff are able to provide state-of-the-art EOL Care. • You and your family will be satisfied with HOL enrollment and follow-up care • You and your family's goals of treatment will be met • You will be satisfied with the control of your symptoms and suffering at end of life • You and your family members will be satisfied with your end of life experience, given your medical circumstances

26. Organizational Health Care Design Elements • Prepared Practice Teams • Activated and informed patients and families • Health Information Support

27. Health Care Delivery Design Prepared Practice Teams Activated Informed Patients Venues Home Hospital Clinic Nursing Home Expanding Options at EOL Goals of Care Self Determined EOL Closure Safe and Comfortable Dying Effective Bereavement Health Information Support Goals of Treatment Epic Web: Plan of Care Advance Directive Ethical Will

28. Staging of the End of Life Care Project Expert Panel Review • End of Life Care Content • Goals and staging of the project • Stage I: Internal Hospice Program Focus • Stage II: Organizational Focus • Stage III: Membership Focus

29. Stage I: Internal Focus Hospice of the Lakes Health Information Support • Comfort Assessment • Standardize Administration • Develop Report format for IDG rounds and EPIC Web Reports • BTI Software (Medicare Eligibility Criteria and professionally managing End of Life Care) • Health information support for Clinicians • Develop Reporting and quality assessment functionality

30. Stage I: Internal Hospice of the Lakes Focus Activated and Informed Patients and Families • Focus group on comfort assessment and End of Life services Prepared Practice Teams • Interdisciplinary group to review patient flow into and through hospice as well as interdisciplinary functioning

31. Stage II: Organizational Focus

32. Educating Physicians in End of Life Care -- EPEC • Gaps in EOL Care • Legal Issues • Elements – Models of Care • Next Steps • Advance Care Planning • Communicating Bad News • Whole Patient Assessment • Pain Management • Physician-Assisted Suicide • Depression, Anxiety, Delirium • Sudden Illness • Medical Futility • Common Physical Symptoms • Withholding/Withdrawing treatment • Last Hours of Living

33. Organizational Focus: Seamless Caring Across Venues Home Patient and Caregiver Plan of Care Comfort Assessment Medicare Eligibility Clinic Hospital Nursing Home

34. Stage II: Organizational Focus Prepared Practice Teams • Develop End of life Care Plans that insure seamless transfers of care across venues of care—admit from hospital • Educate and support prepared practice teams capable of smooth handoffs • EPEC Training for • GNPs • Hospitalists • ER Physicians • HPMG Physicians, Nurses and Social Workers • Palliative Care Consultation Team Regions Hospital

35. Stage III: Member Focus Activated and Informed Patients, Members and Families • Advanced care planning • Opportunities and challenges at the end of life • Addressing pain and suffering: Palliative Care and chronic illness

36. PLAN DO ACT STUDY

37. Act II: New model • Accountability and Patient Centered Changes • Admit patients within 24 hours • Admit from the hospital, avoid sending patients home with complex medication management regimens • No vending of patients • Focus on National productivity standards and conditions of participation • Initiate new model of care: self-managed teams

38. Self-managed Care Teams • Definition: Self-managed teams are groups of interdependent individuals that can self-regulate their behavior on relatively whole tasks; responsibilities may include setting work schedules, developing performance, dealing directly with external customers, selecting own members and evaluating one another’s performance. In Cohen et al. A predictive model of Self-Managing Work teams, “Human Relations”, May 1996.

39. Predicted advantages • Empowered employees • Quicker decision-making • Greater continuity: “We are your care team” • Increased closeness to patients, caregivers, & care teammates • Increased efficiency • Increased flexibility

40. However, to implement… • But: increased employee training is necessary so that staff know their jobs “inside and out” and can turn to each other as resources rather than supervisors. • And: Supervisors must allow staff to “do their jobs” while maintaining responsibility for operational oversight and compliance (COPs) and care coordination.

41. Expectations • Each team would be able to care for 25 to 28 patients

42. Evaluation, Outcomes and Problems 2003- 2005 • Increased census from 80 to 140 initially, then to 160; increased from 4 teams to 8 teams • Developed an admission team • Lack of competent team supervisors • Poor understanding of the concept of self-management teams • No clear role or authority for supervisors in the model • Tremendous amount of ill will between staff and management • Number of staff left the program or were let go

43. Increasing census and requirements Load vs HOL horsepower Hospice of the Lakes “horsepower” hauling the load Year 2005 Year 2001

44. Advice to new leadership team?

45. Act III: Descriptive Sneaks in • 2006 to present • 2004 hired a new volunteer coordinator • Program director becomes ill in Mar 2005, officially resigns in 2006 • Hired new clinical supervisors • Division Director decides not to fill the program director position, steps in as facilitator and invites me to be an active consultant-participant in the management team

46. Increasing census and requirements Load versus HOL horsepower Hospice of the Lakes “horsepower” hauling the load Year 2008 Year 2006

47. Supervisory and Change Strategies • Engaging the actors not the critics (involvement and engagement) • All Staff meetings became “campfire conversations seeking the wisdom of everyone to solve a problem or how best to change • Get extensive input from affected staff prior to making a change

48. Early changes • March 2006: facilitated offsite by outside consultant for the new management team • Create new leadership mission, vision and accountabilities for the leadership group • All of the managers and supervisors became the leadership team: PALS • Focus on serving and supporting our staff so that they can provide STEEEP care • Leadership and management commit to working as a team

49. Developing a leadership and management team • Meeting Hygiene • Getting in “harness” weekly in a recognizable format • Tracking problems, interventions, outcomes • Facilitation and evaluate each meeting • Management Rounds for supervisors • Everyone brings their tough cases and work together on developing social practices that are recognizable and effective – (create a culture of decision-making principles, social practices on managing conflict) • Create safe environment where supervisors can be direct with each other and recognize when they are being triangulated

50. Large Scale change needed • D x V x F > R • March 2007 taking stock • High dissatisfaction among old-timers • Still significant underground of rumors, dissatisfaction and perception of the culture at HOL (intimidation, unfriendly, not enough preparation for new persons, etc)