PATIENT CARE CoPs: INTERDISCIPLINARY GROUP, CARE PLANNING, AND COORDINATION OF SERVICES HOW TO PREPARE HOSPICE REGULATORY BOOT CAMP Joy Barry, RN, MEd, CLNC Principal Weatherbee Resources, Inc Hospice Education Network, Inc Hospice Quality Resources, LLC OBJECTIVES At the end of this session, participants will be able to: 1. List the tools necessary for appropriate care planning. 2. Describe the D.A.R.E. IDG meeting format. 3. List the functions of the IDG meeting facilitator, timekeeper, and scribe. 4. Name an effective hospice facility care planning strategy. HOW TO PREPARE THE TEAM THE TOOLS THE TECHNIQUE
THE TEAM Prepare IDG for new CoPs implementation: Appoint IDG responsible for establishing agency P&Ps. Review new CoPs with IDG. Identify changes necessary for compliance. Educate RNs re care coordination responsibilities. THE TOOLS Revise care planning tools: Allow for identification and documentation of Problems, Interventions, and Goals (PIGs). Allow for specificity regarding disciplines, visit frequencies, and what needs are being addressed. TOOLS, CONT D. Prompt documentation of attending MD and pt/fam collaboration (if they so desire). Reflect provision of education appropriate to care and services to be provided by pt/fam.
TOOLS, CONT D. Determine methods of communication and care coordination (e.g., voice or e-mail, IDG meetings, report line, fam meetings, case conferences, etc.). Ensure IDG communication modalities are adequate, efficient, and reliable. TOOLS, CONT D. Define the term change in condition. Provide ongoing education to hospice, contracted and facility staff. Provide education to pt/fam and/or PCG, as needed. Ensure timeliness of communication and POC updating whenever a change in condition occurs. THE TECHNIQUE Re-tool IDG meeting, as needed. Effective IDG meetings include: Structured meeting format; Focus on POC; and Solid documentation.
STRUCTURED MEETING FORMAT Adopt D.A.R.E. format: D Deaths (include all discharges, transfers and revocations); A Admits; R Recertifications; and E Existing pts (grouped per diagnosis / LCD category). FORMAT, CONT D. Write LCD guidelines on newsprint and post in meeting room. Group recerts and existing pts according to diagnosis. Utilize LCDs when discussing pts, anticipating problems, reviewing eligibility, and recertifying. Teach LCDs to all IDG members and reinforce their use in clinical notes. PIG-OUT! IDG meeting is pt/fam time: Focus should be on PIGs & outcomes ( PIG-OUT!). Anticipatory care planning, based on active disease trajectory and assessments. Utilize hospice MD as IDG resource. What would pt/fam say if at meeting?
FORMAT, CONT D. Appoint: A facilitator; A timekeeper; and Scribes. Encourage all IDG members to have a voice in each meeting. Rotate members through roles to encourage inclusion. FORMAT, CONT D. Facilitator: Opens meeting; Ensures all IDG members are present; Makes any announcements; Keeps meeting focused and moving forward; Encourages mini meetings outside larger group as needed; and Ensures all documents are signed. FORMAT, CONT D. Timekeeper: Ensures all scheduled pts are reviewed; Ensures individual pt/fam discussions stay on track; Respectfully shuts down tangents and side conversations; and Reminds IDG that DNR means DO NOT RAMBLE!
FORMAT, CONT D. Scribes document clinical notes reflecting: POC review / updating; IDG discussions / decision-making; MD certification / recertification discussions with IDG, as needed; Anticipated visit frequencies for upcoming 15 days; etc DOCUMENTATION Appointing scribe allows IDG to focus thoughts & dialogue on specific pt/fam. Any IDG member not actively involved with pt being reviewed can be a scribe. Members doing the dialoguing should review and approve scribe s notes prior to filing in clinical record. DOCUMENTATION, CONT D. Document: MD & IDG discussions and decisions, especially with regard to hospice eligibility. Related and unrelated conditions. Progress toward outcomes.
DOCUMENTATION, CONT D. Focus POC reviews by stating: 1. The results of my pt/fam assessment are 2. The pt/fam outcomes we re focusing on are 3. The priority for my next visit is 4. My anticipated visit frequency is HOW TO PREPARE Read new CoPs. Determine needed policy and procedure changes. Amend documentation tools (or buy new ones). Observe IDG meeting. PREPARING, CONT D. Change what is! Elicit staff buy-in and participation. Pilot new tools and processes quickly, and amend as needed, prior to agency-wide implementation. Provide staff sufficient and timely education regarding all changes. Audit for compliance.
PREPARING, CONT D. Revise scheduling / tickler system to reflect new 48-hr, 5-day & 15- day requirements. Audit to ensure compliance. PREPARING, CONT D. Keep IDG meeting focused on pt/fam & POC (PIGs). Do not allow meeting to go on too long or IDG to ramble. Accomplish care planning versus reporting. PREPARING, CONT D. Identify new PIGs. Document problem resolution. Specify & follow individualized visit frequencies. Document recertification discussions & measurable clinical data points to support eligibility.
PREPARING, CONT D. Ensure POC: Drives all care and services. Reflects problems based on initial, comprehensive, and updated assessments. Reflects care is in accordance. PREPARING, CONT D. Critical Referral Question Initial Assessment Comprehensive Assessment Plan of Care Reassessment and POC Review Recertification 3 LITTLE PLANS 1. Mr. Jones Glioblastoma 2. Mr. Doe COPD 3. Mrs. Smith Dementia
COMPLEX HOSPICE PATIENTS Diagnoses: Organ System Failure, Dementia, Infectious Disease, Neurodegenerative Disease, Cancer. Comorbid Conditions: Different from primary diagnosis, but may be contributory to death. Secondary Conditions: Complications directly related to a primary or comorbid condition. Health Status Decline Death Time Resource: Field MJ, Cassel CK (eds), Institute of Medicine. Approaching Death: Improving Care at the End-of-life. Washington, DC: National Academy Press. 1997 HOSPICE POC Problems Based on comprehensive assessment of pt/fam needs. Interventions Related to terminal diagnosis; palliative in nature. Goals Designed to eliminate futile, unwarranted/unwanted treatment; to keep pt home ; and to assure comfort and pain/symptom management. SAMPLE POC MR. JONES PROBLEMS 1. Pain 2. Impaired judgment 3. Aphasia 4. Imminent death 5. Spiritual distress INTERVENTIONS 1. Verbal/non-verbal pain scales; meds A/O; stimulation (dark room, quiet, soft music PRN); ice pack to forehead; sunglasses; massage therapy GOALS 1. Maintain SIT score of 3 or below.
SAMPLE POC MR. DOE PROBLEMS 1. Impaired breathing 2. Anxiety 3. Weight loss 4. Depression INTERVENTIONS 1. O2@3L via NC cont; conserve energy (freq rest periods, break tasks into multiple short steps); ask yes/no questions; soft foods; clear liquids, meds A/O; teach relaxation GOALS 1. Maintain O2 sat above 90% to feelings of air hunger SAMPLE POC MRS. SMITH PROBLEMS 1. Altered skin integrity 2. Safety 3. Weight loss 4. Impaired swallowing 5. Potential for infection INTERVENTIONS 1. Assess skin q visit; Rx A/O; measure wound q wk; photo per policy; pain meds PRN A/O; HA to temp q visit; room deodorizer GOALS 1. Maintain comfort; prevent worsening & infection; eliminate odor; and resurface. NURSING FACILITY POC Problems Facilities are cited on survey for negative pt outcomes (e.g., skin breakdown, weight loss, infections, falls, physical / chemical restraints). Interventions Usually aggressive in order to prevent negative outcomes. Goals Typically restorative / rehabilitative in nature; designed to maintain or improve current level of function.
SAMPLE SNF POC MRS. SMITH PROBLEM Altered skin integrity. INTERVENTION Hospice interventions plus: MVI; Megace; Ensure TID; double portion / high PRO diet; T&P q 2 hrs W/A; special skin care after incontinence; air mattress; gel W/C cushion; etc GOAL Skin breakdown will be resolved in 90 days. SAMPLE SNF POC MRS. SMITH PROBLEM Weight loss. INTERVENTION MVI; Megace; double portion / high PRO & CAL diet; Ensure TID & when intake <50%; health shakes with med pass; wkly weights; etc GOAL Pt will gain 1 # per week X 10 weeks. WEIGHT LOSS Not unexpected at end of life. Not necessarily a problem. Related issues would be addressed: Honoring pt s food choices / preferences. Assistance with food prep and feeding. Preventing / addressing skin breakdown. Aspiration precautions.
HOSPICE FACILITY COLLABORATION Certain negative outcomes may be unavoidable at end of life. Facilities not typically cited on survey when hospice pts experience weight loss, skin breakdown, etc. Important to communicate this info to facility staff and collaborate on appropriate care planning. Clarify whose goals of care are they? QUESTIONS THANK YOU! Joy Barry, RN, M.Ed., CLNC Principal WEATHERBEE RESOURCES, INC HOSPICE EDUCATION NETWORK, INC HOSPICE QUALITY RESOURCES, LLC 259 North Street Hyannis, MA 02601 508-778-0008 jbarry@weatherbeeresources.com