Driving Advanced Care Planning

Transcription

1 Driving Advanced Care Planning Palliation model in Post-acute, Long Term Care Laura Seleen RN System Long Term Care Clinical Specialist Essentia Health St. Mary s 1027 Washington Avenue Detroit Lakes, MN Phone: Fax: Cell: Internal Extension in Detroit Lakes Laura.seleen@essentiahealth.org

2 Objectives Identify the benefits of on-going discussions about preferences for care Gain understanding of how to over come challenges of care delivery in SNF using Advanced Care Planning Outline a workflow design that promotes best practice for Advanced Care Planning in SNF s Describe measurements of successful Advanced Care Planning

3 Challenges and Opportunities of Palliative Care in SNF No payment source other Part B Medicare of provider visit (CPT codes st 30 minutes each additional 30 minutes) Providers geared to treat conditions, or end of life hospice Advanced Directives are often not detailed past the DNR (POLST) Requires team coordination SNF motivation ($$) is to rehabilitate

4 Advanced Care (Palliative Care) VS Hospice All hospice care is palliative however, not all palliative care is hospice. Think of hospice as a specialty with in palliative care. Palliative care establishing that detailed Advanced Directive Palliative Care is about management of symptoms Palliative Care can normalize the end of life by eliminating the jagged road of multiple acute care episodes

5 Motivation? A Must read book: Being Mortal by Atul Gawande This book was recommended by our Medical Director, Dr. Henke My take a way's: End of Life does not have to be a roller coaster of acute care episodes Health care does not always do diligence to end of life needs and requests Many do not understand health care options What happens between Full acute care and Hospice care Long Term care is plagued with regulation and barriers that limit our interpretation of care delivery

6 Being Mortal

7 Being Mortal FRONTLINE follows renowned New Yorker writer and Boston surgeon Atul Gawande as he explores the relationships doctors have with patients who are nearing the end of life. In conjunction with Gawande's new book, Being Mortal, the film investigates the practice of caring for the dying, and shows how doctors -- himself included -- are often remarkably untrained, ill-suited and uncomfortable talking about chronic illness and death with their patients.

8 Situation (Handout) Health Care Campus Hospital, PAC, SNF, AL, Sr. Housing, HHC No models of Palliative Care available Gap in understanding Palliative Care Provider with the passion and knowledge of Palliative care HCD offered (no formal program)

9 Background Health community provides 2 levels of care: Acute Care (hospitalization) or Hospice. Families and Residents resistant to hospice or comfort care (represents end of life) Seeing repeated hospitalizations for chronic conditions in our data

10 Assessment Chronic Diseases/symptoms need to be managed when cure is no longer appropriate Clinical model for palliation needed Need to identify how palliation can exist with current programs without overlap Need to start small and pilot a program

11 Recommendation Charter a Team to develop program Find training for HCD facilitation Communicate to providers PDSA pilot and continue to communicate needs

12 Name for Team Comfort Care Team: This term has been used in our facility for years, and was interchangeable term for end of life care. Families and residents not always willing to accept because of the idea that this was the end of the road for them Palliative Care Team: There is also a reluctance to use this term for the same reason, and a lack of understanding of what this really means Advanced Care Team: When families and Residents here this term, they feel like it is saying special care. Once explained to them, it seems thus far acceptable

13 Development of the Advanced Care Team Write an outline/p&p to begin our program Initiate Screening tool Develop Orders Develop Standing Order Set (EMR Matrix Care) Set up billing Code for GNP visit Send team to Train the Trainer Advanced Directives Training PDSA on small population

14 Advanced Care Management Options Consultation Assessment and treat Assume Care

15 Advanced Care Orders (Handout)

16 Team Communication Weekly huddle to review care management What is working well? Where are we stuck? What is our next steps? Monthly Charter for program development

17 Success Story H is a Resident of Oak Crossing. H went through a life changing event (Stroke) and lost ability to swallow Regular foods. H is our first Resident managed by the Advanced Care Team. One of H s loves was a visit from family who would bring in Chinese foods, and with current diet orders, could not have Chinese foods. With the QOL assessment performed by the team, confirmation/documentation, provider visit and team meeting, it was determined that the benefit of Chinese food/visits from family outweighed the risk of having Chinese food. It was simple. H is very happy and the team feels accomplished in assisting to achieve QOL for H.

18 Other Considerations Comfort modalities (Namaste room and portable Namaste cart) Essential Oils Frequent Team Huddles Train all staff in comfort measures and Advanced Care team Process Hospice when appropriate

19 A Framework for Improving End of Life Care (Handout) Getting Started: 1.Collect Baseline Data 2.Understand current process 3.Identify a subpopulation Framework for improving end of life care 1.Engage 2.Steward 3.Respect 4.Exemplify 5.Connect White paper: Conversation Ready available at ihi.org

20 What is your Story? SBAR exercise: Get in groups of 3-4 What is your story? Develop your SBAR Who will you present this too?

21 What is your SBAR? (Group discussion)

22 Our Journey so far

23 Celebrate Aging Expo

24 Health Care Directive Assistance

25 Aging Expo DL magnet handout

26 Seminar

27 Health Care Directives Presentation (Handout)

28 Next steps New role: Mission Integration Director (Bringing the internal and community strategies together Fine tune assessment tools/standardize EMR Continue training (step 2) of Train the Trainers Follow up Community requests/educate Educate Essentia Health and Sanford providers Measure success (Reduce hospital admissions, Reduce urgent Care or ER visits, Satisfaction, #HCD s, Comfort) Evaluate opportunities for team consult for inpatient review and outpatient clinic Community event ( Being mortal ) transitions team

29 Benefits At the end of the day We are making a healthy difference in peoples lives. Providing Community service Being good stewards of our Medicare dollars (ACO)