Care Initiation: Crisis Management

Transcription

1 VNAA Blueprint for Excellence Pathway to Best Practices Care Initiation: Crisis Management VNAA Best Practice for Hospice and Palliative Care: End of Life

2 This presentation addresses crisis management for newly admitted patients (crisis admission) and those who have been on the program (currently enrolled patient). CARE INITIATION frequently includes responding to patients/caregivers in crisis due to factors surrounding the hospice admission. Quality of care is dependent on anticipating the cause of the crisis and quickly responding. This is also important because 25% of all patients have lengths of stay of 7 days or less with 10% at 3 days or less. Although only a small number of patients are discharged to an acute care facility (2-10%) these cases may reflect the need for more proactive interventions when a crisis arises.

3 Why Crisis Management Hospice professionals frequently encounter patients/caregivers in crisis. Symptoms or physical or psychosocial issues may emerge any time. Crisis level care (Continuous Home Care or General In Patient Care) are required by Medicare COPs. Crisis admission visit and crisis care require a specialized skill set. Patients who have been stable may enter a crisis due to uncontrolled symptoms.

4 Definition of Best Practices 1. The hospice program has a mechanism in place to identify the risk of a hospice admission being a crisis admission for the patient and/or caregiver. 2. An intervention plan for the initial visit addresses those identified high risk issues. 3. The hospice program has a plan in place to respond to patients already enrolled in hospice if a crisis develops. 4. For a patient in crisis hospice personnel provide Continuous Care at home or if the crisis cannot be managed at home transfer the patient to General In-Patient care at a facility.

5 Critical Interventions/Actions: Crisis Admission Intake staff should be trained to identify red flags that indicate a possible crisis admission. (See VNAA Crisis Management Module for list of red flags). Additional support or information may be needed by caregivers to help make the hospice decision. Involve both nursing and social work in the initial visit. Quick assessment of the patient is crucial during the initial visit.

6 Critical Interventions/Actions: Crisis Admission-2 Train staff to evaluate patient/caregiver s ability to learn and to administer medications. Staff should explore available support systems. Explore goals of care related to CPR and rehospitalization and other treatment preferences and document. Evaluate the patient and caregiver s understanding of the nature of hospice care.

7 Critical Interventions/Actions: Currently Enrolled Hospice Patient Staff should be trained in developing therapeutic relationships. Ask the patient/caregiver to describe their concerns and any steps they may have taken to address them. Work closely with community providers and facilities whenever needed. Identify the most problematic issues and develop interventions to resolve them. Training for staff in developing a therapeutic relationship See VNAA Artful Conversations Module for details.

8 Critical Interventions/Actions: Currently enrolled hospice patient-2 Ensure that the patient/caregiver are comfortable with the POC. Identify and document changes in symptoms from the acceptable baseline. Crisis assessments should be focused, brief and symptom oriented Identify specific service needs.

9 Critical Interventions/Actions: Currently enrolled hospice patient-3 Training for patients and caregivers should include: A plan for preventing common symptoms Education and plan for care in the final days/hours. Coaching on possible scenarios such as cardiac/respiratory failure, other applicable symptoms How to communicate with the hospice during and after hours.

10 Critical Interventions/Actions: Currently enrolled hospice patient-4 Symptoms should be under control by end of visit. If not, Continuous Care or General In-Patient care should be arranged or initiated. Provide education and information to patients/caregivers both on symptom management and emergency care. An emergency plan should be consistent with the patient s documented treatment preferences

11 Measurement 1. The hospice has an admission crisis risk assessment in place and documented for each new referral. (Y/N) 2. Documentation in the clinical records demonstrates interventions targeted to each identified risk.(y/n) 3. Staff training including how to respond to crisis is documented for each member of the IDT. (Y/N) 4. For each patient in crisis, the clinical record demonstrates that staff either stay with the patient until the crisis is resolved or an alternative level of care is implemented.

12 References and Supporting Documentation Teno J.M., Shu J.E., Casarett D., Spence C., Rhodes R., Connor S. (2007) Timing of Referral to Hospice and Quality of Care: Length of Stay and Bereaved Caregiver Member. J Pain Symp Mgt. Aug; 34(2); Anewalt, cauthor_uid= NHPCO. Managing Continuous Home Care For Symptom Management Tips For Providers Available at: Registered Nurse Association of Ontario. Nursing Best Practice Guideline - Shaping the future of Nursing: Establishing Therapeutic Relationships. July 2002, revised Available at: