Objectives. Objectives cont. 8/19/2016. Making the Most of Your IDT Care Plan Update Meeting

Size: px

Start display at page:

Download "Objectives. Objectives cont. 8/19/2016. Making the Most of Your IDT Care Plan Update Meeting"

Ashlyn Clarke
5 years ago
Views:

1 Making the Most of Your IDT Care Plan Update Meeting Marisette Hasan RN VP, SC Operations The Carolinas Center for Hospice and End of Life Care address: (mobile) Objectives Participants will receive an overview of the CMS CoPs regarding the IDG team and the Care plan update meetings. Participants will identify the role of the each IDG members to enhance the IDG Care Planning process. Participants will recognize the preparatory steps needed to make the IDG care plan meetings meaningful. 2 Objectives cont. Participants will verbalize barriers that hinder the success of the IDG meeting. Participants will identify at least 2 action items to improve the IDG meeting process and outcomes in their organization. 3 1

2 THE IDG and the CoPs Interdisciplinary Group, care planning and coordination of services The hospice must designate an interdisciplinary group or groups as specified in paragraph (a), which in consultation with the patient s attending, must prepare a written plan of care for each patient. The plan of care must specify the hospice care and services necessary to meet the patient and family specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions. THE IDG and the CoPs (a)(1) Standard: Approach to service delivery The hospice must designate an interdisciplinary group or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional and spiritual needs of the hospice patients and families facing terminal illness and bereavement. Core Members of the IDG (a) (1) The interdisciplinary group must include, but is not limited to, individuals who are qualified and competent to practice in the following professional roles: (i) A doctor of medicine or osteopathy (who is an employee or under contract with the hospice). (ii) A registered nurse. (iii) A social worker. (iv) A pastoral or other counselor. 2

3 Coordination of Care (a) (1) The RN, a core member of the IDG, is responsible for the following activities: 1. Coordination of care 2. Continuity of care 3. Continuous assessment of patient and family needs 4. Implementation of the interdisciplinary plan of care. Development of the IDG Plan of Care (c ) The hospice must develop an individualized written plan of care for each patient. The plan of care must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: Development of the IDG Plan of Care Interventions to manage pain and symptoms Scope and frequency of services Anticipated measurable outcomes through the implementation coordination of the plan of care List of drugs and treatments Medical supplies and appliances Documentation of the patient s and family s understanding and agreement with the plan of care based on their wishes. 3

4 418:56 (d) Review of the Plan of Care The hospice interdisciplinary group (in collaboration with the individual s attending physician, if any) must review, revise and document the individualized plan as frequently as the patient s condition requires, but no less frequently than every 15 calendar days. A revised plan of care must include information from the patient s updated comprehensive assessment and must note the patient s progress toward outcomes and the goals specified in the plan of care (e) Coordination of Services The hospice is responsible for developing and maintaining a system of communication and integration to ensure the following: 1. The IDG directs, coordinates, supervises the services that are provided 2. Services are provided in accordance with the plan of care 3. Care is provided based on the assessments and the identification of the patient and family needs (e ) Coordination of Care cont. 4. Provide for and ensure ongoing sharing of information related to the patient s and family s care and needs among all disciplines providing care and services in all settings, whether provided directly or under arrangement. 5. Provide for ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. 4

5 IDG Care Plan Meeting: Preparation Each case manager should review the following prior to the meeting: 1. Patient progress towards goals established in the IDG Plan of care in the past 2 weeks: Functional Decline, DNR status, altered mental status, etc. (Change in level of care?) Medication changes (updated med list) Additional IDG service needs, frequency changes, aide care plan updates, etc. Hospitalizations/Revocations Recertifications/Discharges IDG Care Plan Meeting: Preparation 2. Team Member Goals, Service Delivery Needs and Visit frequency Physician/NP: Recertification narratives, F2F visits, med consultations, etc. SW: emotional needs, funeral plans, support for caregiver, community resources, etc. Chaplain: Spiritual needs, conflicts, spiritual rituals, community connections, funeral plans, spiritual themes (anger, acceptance, etc.) Volunteer Support: Currently visiting, need a volunteer, frequency changes, etc. Bereavement Care: deaths in the past 15 days, IDG Care Plan Meeting: Preparation 3. Other Updates or Consultative Supports to review Pharmacy consultation-d/c meds due to change in level of care, efficacy issues with current med, etc. DME updates Ancillary support team needs?: PT/OT/Speech Hospice Aide Care Plan Updates/Supervision 4. Document updates in the EMR prior to the meeting starting- 5. Have concise notes prepared to discuss during the meeting that are focused on the care plan goals 5

6 IDG Meeting: The Role of the Facilitator The facilitator has the room ready and calls the meeting to order. The facilitator sets the stage by being prepared with a hard copy list /or having the EMR list ready Based on the allotted time the facilitator must keep the discussion focused on the review of patients goals achieved, revisions needed, and updates to the plan of care, IDG Meeting: Team Collaboration and Updates Each team member should be acknowledged and be given time to share their updates or the assessed anticipated needs of the patient and family. Team members who are not assigned to a patient, should also weigh in on the needs addressed during the meeting and document recommendations. How does your team determine the goals of care? Who is involved in the discussion? Barriers to a Successful IDG Care Plan Update Meeting MD is unavailable or disengaged Poor administrative and clinical team preparation Lack of respect for each discipline and the IDG Care Planning Process Side bar conversations displays lack of value and respect for the team collaboration process Poor time management during the meeting 6

Discussion & Questions What can you do to improve or enhance your IDG Care Plan Update Meetings? 19 Resources CMS Hospice Center Website www.cms.

7 Discussion & Questions What can you do to improve or enhance your IDG Care Plan Update Meetings? 19 Resources CMS Hospice Center Website Chapter 9 of the Medicare Benefit Policy Manual (Publication ) Guidance/Guidance/Manuals/Downloads/bp102c09.pdf 7

Subpart C Conditions of Participation PATIENT CARE Condition of participation: Patient's rights Condition of participation: Initial

Subpart C Conditions of Participation PATIENT CARE 418.52 Condition of participation: Patient's rights. 418.54 Condition of participation: Initial and comprehensive assessment of the patient. 418.56 Condition