Module 6: End-of-Life Care in the Skilled Nursing Center Lesson 2 NE QIN-QIO & Good Shepherd Community Care This material was prepared by the New England Quality Innovation Network-Quality Improvement Organization (QIN-QIO), the Medicare Quality Improvement Organization for New England, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. CMSQIN_C2_201508_0198
Module 6 Lesson 1 Intro to Palliative Care Programs Lesson 2 Components of A Palliative Care Program Lesson 3 Measuring Change Lesson 4 Partnering With Hospice Providers Caring for Our Community with Compassion Since 1978 2
Lesson 2 Part 1: Skills and Care Practices for Palliative Care Part 2: Learning Activity to Build Palliative Care Infrastructure
End-of-Life Care in the Skilled Nursing Center Lesson 2: The Components of a Palliative Care Program Part 1: Skills and Care Practices for Palliative Care Sheryl Leary, LSW Program Administrator Safe Transitions New England QIN-QIO
In this Lesson: Part 1 Let s explore building the palliative care infrastructure within a skilled nursing facility Two Sources: Neuendorf, Kathleen, and Mellar Davis. "Palliative Care." Cleveland Clinic: Center for Continuing Education. Cleveland Clinic, June 2014. Web. 4 Aug. 2015. Developed by Healthcentric Advisors, June 2014, available www.healthcentricadvisors.org
Cleveland Clinic Publication 7 Major Skills for Palliative Care Communication Decision-Making Management of Disease-Related Complications Symptom control Psychosocial and Spiritual Care Care of the Dying Coordination of Care
RI Nursing Home Palliative Care Collaborative 6 Domains of Palliative Care Identifying Proxy Decision- Makers Advance Care Planning Pain Assessment Discussion of Patient Diagnosis Discussion of Patient Goals Assessment and Access to Spiritual Care
Skills and Care Domains Advanced Care Planning Assessment of Spiritual Care Discussion of Resident Goals Communication Pain Assessment Discussion of resident prognosis Identifying proxy decisionmakers
Change Ideas Ask what the patient already knows and what he or she wants to know Ask how the patient wants to hear the information by himself or with family
Skills and Care Domains Identifying Proxy Decision- Makers Decision Making Discussion of Patient Goals Advance Care Planning
Change Idea As a provider, ask yourself these three questions with each patient: What is the plan of care? What are the goals of care this patient identified? Does the plan of care and goals of care make sense for this patient?
Skills and Care Domains Pain Assessment Assessment and Access to Spiritual Care Treatment of Complications and Symptoms Discussion of Resident Prognosis Advance Care Planning Discussion of Resident Goals
Change Idea Ask your patients directly to rate their symptoms and use standardized, evidencebased assessment tools
Change Idea Review your process for making hospice and palliative care referrals. Are you making them early enough to fully benefit the patient?
Skills and Care Domains Advance Care Planning Pain Assessment Psychosocial and Spiritual Care Discussion of Resident Goals Discussion of resident prognosis Assessment and Access to Spiritual Care
Change Idea Review how you use Social Work support on your team. Do you call in your social work team before a crisis? Do family meetings include time for educating families?
Change Idea Consider the difference between spirituality and organized religion within your assessment.
Skills and Care Domains Advance Care Planning Identifying Proxy Decision- Makers Pain Assessment Care of the Dying Discussion of Resident Prognosis Discussion of Resident Goals Assessment and Access to Spiritual Care
Change Idea Train your care team to recognize the psychological and biological indicators that death may be imminent Be sure that prognosis discussions include the multidisciplinary team so that all care team members can offer support and services
Skills and Care Domains Identifying Proxy Decision Makers Access to Spiritual Care Coordination of Care Advance Care Planning Discussion of patient goals Discussion of patient prognosis
Change Idea Implement an evidence-based program to improve care coordination with external providers, such as INTERACT Identify how your team prepares for Care Plan meetings and find the opportunities to improve internal communication
Summary Recognize the skills and care practices that are involved with palliative and endof-life care Develop change ideas for the skills and care practices that need improvement Next Lesson 2, Part 2
Module 6 Lesson 1 Intro to Palliative Care Programs Lesson 2 Components of A Palliative Care Program Lesson 3 Measuring Change Lesson 4 Partnering With Hospice Providers Caring for Our Community with Compassion Since 1978 23
Lesson 2 Part 1: Skills and Care Practices for Palliative Care Part 2: Learning Activity to Build Palliative Care Infrastructure
End-of-Life Care in the Skilled Nursing Center Lesson 2: The Components of a Palliative Care Program Part 2: Learning Activity to Build Palliative Care Infrastructure Sheryl Leary, LSW Program Administrator Safe Transitions New England QIN-QIO
Learning Activity Review your facility s quality measures and your QAPI charter to determine your area of need.
Learning Activity Determine the skill and care domain area that would be most appropriate for your facility to work on Discussion of Patient Prognosis
Learning Activity Develop your Performance Improvement Project (PIP) outline around a change idea related to a skill and care domain Build a P-D-S-A cycle and based on results Abort the change Adapt the change Adopt the change
Learning Activity Resources QAPI Charter, PIP Outline and PDSA information available at www.healthcarefornewengland.org in the Pre-Work section Standard Analytic Report (SAR) available from your state QIN-QIO Nursing Home Lead
Learning Activity Resources Review supporting documents including the Nursing Home Palliative Care Toolkit at www.healthcarefornewengland.org Series 1 Transitions of Care: Learning Module 6
Summary Decide which skill and/or care practice you want to focus on in your facility Build a PDSA cycle Use the resources available to you through this learning series Next Module 6, Lesson 3