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Working Better Together – Hospice & Nursing Homes. Jeff Baker, RN, CHPN , Susquehanna Health Home Care & Hospice Bobbie Woolcock, BSN, RN, CNDLTC , Muncy Valley Hospital Skilled Nursing Unit May 19, 2011. Muncy Valley Skilled Nursing Facility SNU 138 beds
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Working Better Together – Hospice & Nursing Homes Jeff Baker, RN, CHPN, Susquehanna Health Home Care & Hospice Bobbie Woolcock, BSN, RN, CNDLTC, Muncy Valley Hospital Skilled Nursing Unit May 19, 2011
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
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 2008 JAMDA 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
Defining Roles Nursing Home Nursing CNA’s Social Service Hospice Nursing Home Health Aide Social Service Chaplain Volunteers 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: PROBLEMHospice/End of Life Care RELATED TOFailure to Thrive ; Family's desire to maximize comfort; and for support of Husband, and children. TARGET DATEOn-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 2007 ECS has many capabilities: CNA Picture Charting Physician’s Order Entry E-MAR/TAR Licensed Nurse Charting Other Department Documentation a. Therapy (PT/OT/ST) b. Activities c. Social Services d. Dietary MDS 3.0/Roster/Census and Condition Care Plans Reports Time Clock Information TechnologyMaking the system work ~ Encore Automated plan of treatment Problem-based care plans Easy access to patient information Automated visit entry Bereavement risk assessment Spiritual assessment Physician documentation IDT review and documentation ~ Future Plans Interface capabilities
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
Contact Information Bobbie Woolcock, BSN, RN, CNDLTC, Muncy Valley Hospital Skilled Nursing Unit Muncy Valley Hospital 215 East Water StreetMuncy, PA 17756 (570) 546-4040800-488-4268 bwoolcock@susquehannahealth.org Ann Packer, BSN, RN, Hospice Manager Susquehanna Home Care & Hospice apacker@susquehannahealth.org 1-800-320-7691
