12/6/2016. Objective PALLIATIVE CARE IN THE NURSING HOME. Medical Care in the US. Palliative Care

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1 Objective PALLIATIVE CARE IN THE NURSING HOME Deborah Morris, M.D., M.H.S. Assistant Professor of Medicine The Glennan Center for Geriatrics and Gerontology Eastern Virginia Medical School Describe program development and expansion. Identify benefits of palliative care in the nursing home. Create best practices for your nursing center for advance care planning, palliative care, and hospice Nearly 70 percent of Americans die in a hospital, nursing home or long-term-care facility. 7 out of 10 Americans say they would prefer to die at home. Only 25 percent of Americans actually die at home. Source: Centers for Disease Control (2005) Source: Time/CNN Poll (2000) Medical Care in the US Few cures Live much longer with chronic illness Prolonged dying process Diagnosis Curative Care Dying/ Hospice benefit Palliative Care Death Problems: Symptoms and need occur across the period of illness Dying Phase is difficult to predict Palliative Care Palliative Care GOALS Cure Disease Prolong Life Restore or maintain function Treat symptoms Primary Benefits: Care tailored to patient and family goals The Right Care at The Right Time Helps doctors, patients and families set realistic goals Improves communication between patient/family and health care providers Improves pain/symptom management Improves patient/family satisfaction Improves mortality for cancer patients Improves QOL for all patients, and does not shorten survival Secondary Benefits Reduce hospitalization Reduce costs 6 1

2 Delivering Palliative Care Limited access Limited workforce Not integrated to healthcare system Limited awareness of providers and patients of benefits Inpatient Care SNF Home Outpatient Office CARES Program: Leverage existing palliative care resources to create a collaborative program Site: 170 bed nursing home in Norfolk, Virginia. Collaborators: EVMS Palliative Care (PC) physician System Chaplain, Nursing Center Staff 8 CARES Program CARES Program Phase 1: Phase 1: Education Phase 2: Consultation and Process Revision Phase 3: Develop best practice tools and metrics to expand PC to other nursing centers Baseline assessment of knowledge and attitudes Inservices on core palliative care topics Online curriculum for future staff and ongoing training CARES Program Phase 2: Consult services Process development and EMR tools Comfort order set Goals of Care Family meeting template PC screening tools Initial plan 12 months- took 24months Table 1 : Resident Characteristics N= 170 Age (Years, mean) Range ( SD 15) African American (n, %) 77, 45% Female (n, %) 104, 61% SNF (n, %) 82, 48% LTC 88, 52% Diagnoses Failure to Thrive/Debility 45, 26% Cancer 26, 15% Cardiac 4,2% Pulmonary 10, 6% Dementia/ Neuro 66, 39% Other 18, 11% PAIN Chronic NON-PAIN Pain 1, 0.5% GOALS Table 2: Reason for Referral OF CARE SUPPORT Palliative Performance Scale (PPS) (10) N 149 (mean, SD) Prevalence 54% 66% 82% 88% Full Code (%) 79 2

3 CARES Program Phase 2: Outcomes Hospital 4% LTC Deaths Hospice 96% SNF without hospice 53% SNF Deaths Hospital 22% Hospice 25% System Expansion: Leverage partnerships 2014 discussions with private medical group and hospital to fund PC Nurse Practitioner at 2 sister Nursing Centers 90% Residents with palliative goals were never hospitalized Site 2: PC Nurse Practitioner Site 2: PC Nurse Practitioner System Expansion: Leverage partnerships 2 nd NP replaces MD at Site 1 (funding through partner hospital) MD begins assessment and training at Site 3 (funding through nursing centers) Discussions with partner hospital Program Lessons: Staff and leadership turnover extend timeline Constant education Identify Site Champions Establish primary palliative care best practices 3

4 Primary Palliative Care Best Practices Communication Communication Prognostication Symptom management Not always talked about Diagnosis Prognosis Usually receives MOST (or all) attention Intervention Rarely addressed Goals 20 Resources Theconversationproject.org Communication Best Practices Discuss goals every person, every time (NOT just crisis) Advance care planning Documentation templates Apps and online Best Practices Prognostic tools are a guide of what MAY happen If time is short, priorities change Days to weeks, weeks to months, months to years Anticipate Expected decline function, symptoms and prepare individual/family Prognostication Apps and online Symptom Management fast-facts Best Practices Standard assessment and documentation of symptoms and palliative care needs Consistent evidenced based treatment of symptoms Ordersets 4

5 Screen, Assess, Treat and Document Physical, Emotional, and Spiritual Needs Palliative Care IDT Rounding Tool Name Medical Summary: Age Life limiting illness: Y/N Room Decline: Y/N as evidenced by Admission Prognosis (Eprognosis): Attending Psychosocial: Physical Symptoms: AD/Living Will: On file Y /N Pain: Y/N Legal Decision-maker: at this time Delirium: Y/N Anorexia: Y/N assistance, supplements, When patient loses capacity: Dyspnea: Y/N Nausea: Y/N Determined by: MPOA, Constipation: Y/N guardianship, surrogate laws MAR reviewed Y/N Changes rec Y/N (see below) POST: On file Y/N Depression Screen: Y/N Veteran: Available care plans reviewed. Prior resident/family meetings documented Y/N Spiritual: F Faith or Beliefs: What things do give meaning to resident s life? Resident Goals: curative, palliative, I Importance and Influence: What role do your combination, undetermined beliefs play in regaining your health? C Community: Are you part of a spiritual or Family Goals: curative, palliative, religious community? combination, undetermined Current Efforts: Standardize Primary Palliative Care Best Practices Time Line Practices Relevant Tools Admission Advance care planning (ACP) Identification of Legal decision-makers - Eprognosis Mortality Calculators Assessment of current medical status, prognosis, - PC Screening Tool goals, and needs (physical, spiritual, - IDT Rounding Tool psychosocial) Code status - Goals of care/family Meeting Template Life review and planning - POST Quarterly 12 month prognosis 6 month prognosis Assessment of current medical status, prognosis, goals Assessment of needs (physical, spiritual, psychosocial) and discuss with resident/family Review advance care plan and legal decisionmaker As above and ACP: POST Hospice education As above and ACP: POST - Family Meeting Template - IDT Rounding Tool - Eprognosis Mortality Calculators - FICA Spiritual Assessment - As above - POST - As above - POST Palliative Care Screening Tool Step 1: Screen for palliative care needs - Record information READILY available in the clinical documentation or resident/family encounters. Use this tool within 3 days of admission. Step 2: Assess and meet palliative care needs Check all that apply. If resident meets one or more criteria, consider an order for palliative care consultation. Basic Disease Process o Cancer (metastatic or recurrent) o End stage renal disease o Stroke (with decreased function or o Advanced dementia dysphagia) o Advanced COPD (dyspnea, oxygen o Advanced cardiac disease (CHF EF<25%, dependence) severe CAD) o Other life limiting illness Co-existing conditions or o Considering (or have) PEG/feeding tube o Multiple ER visits (2 or more in past 3 Critical Incidents o Long term ventilator support months) o Stage 3 or 4 pressure ulcers o Multiple hospitalizations (2 or more in past o Recent ICU stay 3 months Domain of Care Possible Needs (check o all that Palliative apply) care consult in Interventions hospital Symptoms o Pain o Decrease function in last (check 1-3 months those that are implemented) (Uncontrolled or Chronic ) o Nausea o Fatigue Physical Comfort/Function o Resident needs pain and symptom o Palliative care consult (pain and symptom o Delirium o Other: management management) Decision-making/ o No Advance directive o Resident or surrogate distressed about o Patient needs help to reach maximum o Physical therapy or occupational therapy Communication o Clinical status calls for discussion/or decision-making desires/possible functional level o Addressed by staff there is conflict about code status Communication/ Decisionmaking diagnosis, prognosis, or treatment plan o SW o Resident/family lack understanding of o Provide education Psychosocial o Limited social support o Spiritual needs: Resident/family exhibit o Resident/family lack of coping skills fear, guilt, or grief o Resident/family need/desire help with o Palliative care consult related to illness, prognosis, etc decision-making (including advance o Addressed by staff directive) o Conflict about treatment decisions Psychosocial/ o Resident/family exhibit anxiety, lack of o SW Emotional Concerns coping skills o Palliative care consult o Resident/family fear, anger, guilt, grief o Spiritual care referral/ connect to community based clergy System Expansion Outcomes % total deaths with %LTC deaths with % resident death Aug-Dec 2015 hospice hospice hospital %death SNF Site 1 38% 66% 7% 32% Site 2a 53% 76% 3% 13% Site 2b 40% 64% 6% 28% Site 3 13% 20% 28% 32% H 6% 8% 35% 48% P 32% 48% 4% 32% % total deaths with %LTC deaths with 2016 TD hospice hospice %death hospital %death SNF Site 1 37% 50% 2% 21% Site 2a 47% 64% 3% 18% Site 2b 74% 89% 3% 15% Site 3 52% 75% 3% 24% H 43% 48% 14% 11% P 26% 36% 3% 19% C 46% 55% 0% 17% All patients & families should receive the RIGHT CARE, at the RIGHT TIME and in the RIGHT SETTING. PALLIATIVE CARE 30 5

6 REFLECT: WHAT CAN YOU DO NOW? CONTACT INFORMATION: Deborah Morris MD, MHS Palliative Medicine Eastern Virginia Medical School 31 6