Reducing Hospital Readmissions Through Appropriate End of Life Care

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1 Cassandra Cotton Cassandra Cotton has devoted more than 18 years to Nathan Adelson Hospice and currently serves as the Hospice s Community Relations and Outreach Coordinator, a position through which she has united her love for hospice and her care and concern for traditionally underserved communities. Ms. Cotton holds a Bachelors of Science degree in Human Services and completed a Masters in Public Administration in She serves on the Advisory Committee for the Nevada Office of Minority Health, the Children Hospice and Palliative Care Coalition, and as the president of the Governing Board of the Nevada Donor Network. Ms. Cotton is passionate about education and awareness regarding end of life care and has presented in various settings to a wide variety of groups. She is the coordinator and developer of Getting Your House In Order, a program designed to provide the faith community with the tools and information necessary to help make choices as they transition through life.

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3 Advance Healthcare Planning (Tools and Resources) Reduction in Hospital Readmissions Learning Objectives Discuss the Share the Care Model(Healthcare Decision Making). Discuss the Advance Directive Model. Discuss Challenges and Barriers (Relative to Decision Making). Discuss Tools and Resources available for Patients and Families relative to AD. Discuss the role of the Healthcare Professional in assisting and Patients and families. Gain an understanding of tools available i.e. Living Will Lock Box, Five Wishes, Nevada Advance Directive. Let s discuss What is Living Will Lockbox? How is it accessed? When is it used? Discuss best practices for implementation in daily operations. Discuss Advance Directives (Advance Directive Bill) Discuss ways to educate patient and families regarding healthcare decision making. Discuss Advance Directive and its tie to readmissions to Hospital 1

4 Some Key Findings (Statistics) WHAT NATIONAL STATISTICS SHOW: 83% of Americans say they want to die at home and pain free. Yet last year only 2.4 million Americans died and fewer than 20% of us died at home and over 80% of us died in a healthcare facility not specialized in EOL care. 24% had verbalized their EOL care wishes to other family members but they unfortunately did not state this in writing. As we see, these are still areas for improvement to consider as we develop our specific outreach plans. RWJ End of Life Initiatives. Pew Research Center Three in 10 people which comes to about 29 % say they have living wills 12 % more than 1990 More than two-thirds of those who are married. 69 percent talk with their spouse about preferred end of life care. That s up by half. Newsmax.com Let's fill our "toolboxes" Share Care Experience Education Cultural Awareness - Tool and Resources- i.e. Living Will Lock Box, Five Wishes, Nevada State Revised Advance Directives,SPIKE Lastly, make it personal( understanding your own perspectives on death and dying). 2

5 Share the Care Patients Understanding of the disease- diagnosis, progression Decision Making Capacity Cultural, Religious, Family, Caregivers Influence of caregiver, friend, faith community, informal Education and Support Collaborations and Partnerships Multidisciplinary Interdisciplinary Tran disciplinary Tools Five Wishes Nevada State (AD ) Advance Directives Living Will Lock Box SPIKES Healthcare Day ( April 16 th, ) National inaugural Set the House in Order Advance Care Planning Model: Four Basic Building Blocks 3

6 Nevada State Advance Directives.. Any person may file an advance directive (NRS ) in the form of a: Declaration governing the withholding or withdrawal of life-sustaining treatment Durable power of attorney for health care decisions Do-not-resuscitate order Nevada State Advance Dire An advance directive pursuant to NRS is a document stating one s wishes regarding end of life decisions, which includes but not limited to a: living will, health care proxy or similar document[s], including organ donor information. NRS A REGULATION relating to advance directives for health care; providing for the electronic storage of advance directives. Five Wishes helps you decide 1. Who you want to make health care decisions for you when you can't make them. 2.The kind of medical treatment you want or don't 3.How comfortable you want to be. 4. How you want people to treat you. 5. What you want your loved ones to Created by Jim Towey know. Jim Towey, an attorney, founded Aging with Dignity in 1996 after his experiences at Mother Teresa s homes for the dying inspired him to promote better care for people facing the end of life. 4

7 Five Wishes Helps to bridge the medical and the legal worlds of advance care planning in a document that is easy for most people to use and understand. Health care professionals use Five Wishes as their preferred advance directive because it improves communication with patients and caregivers, saves time and increases advance directive completion. Many also use customized editions of Five Wishes to raise awareness in their community. Five Wishes Speaks to all of the person s concerns, not just the medical and legal ones. Matters of comfort, dignity, pain management, personal and spiritual issues, family reconciliation and memorial matters are all addressed. It s also easy to use and understand. It meets the legal requirements and has been called the closest thing available to a national advance directive. Five Wishes meets the Nevada Statues Contact: Paul Malley (888) 5-WISHES Cassandra Cotton, Nathan Adelson Hospice (702) James M. O Reilly, Esq. (702) Charles P. Sabatini, Esq. (202) FOR IMMEDIATE RELEASE January 27, 2010 Five Wishes Advance Directive Now Meets Nevada Legal Requirements Nationally-acclaimed advance directive helps Silver State residents express their health care wishes in their own words 5

8 Living Will Lock Box Living Will Lock Box established March 2008 The Living Will Lockbox ensures that Nevadans voices are heard when end of life issues arise. As of June 30 th ,512 registrants. 41 healthcare providers ( Authorized Access) Living Will Lock Box What can be stored Declaration governing the withholding or withdrawal of life sustaining treatment (NRS NB) Durable Power of Attorney of Healthcare Decision( NRS NRS 860). Do-not- Resuscitate Order(NRS.450B.420) Healthcare Decision Day. April 16th Healthcare Decision Day A national day set a side Healthcare Decision Day Nathan Adelson Hospice will host its 4 th Annual More information.. The Center For Compassionate Care 6

9 SPIKES.. Buckman s Six Step Guide Dr. Buckman, R, M.D. Breaking Bad News S.P.I.K.E.S. S etting, listening Skills P atients Perception I nvite patient to share K nowledge transmission E xplore E motion and Empathize S ummarize and Strategize Reducing Readmissions Proactive Actions Training, Workshop, Seminars Initiated conversations concerning Healthcare Decision Move.. (Patients, Families, & Community) Education Empowerment Engagement Sharing the Care Conclusion QUESTIONS, COMMENTS, CONCERNS THANK YOU 7

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