Home Based Palliative Care Across The Age Spectrum

Transcription

1 Home Based Palliative Care Across The Age Spectrum Lessons learned in beginning development 2018 New England Home Health & Hospice Conference and Trade Show April 25, 2018 Greg Burns, BSN, RN, CHPPN MHCAH Palliative Care Coordinator Robert Abel, MSN, RN, CHPN Chief Nursing Officer and Director of Palliative Care

2 Disclaimer We have no affiliations financial or otherwise to report.

3 Palliative Model

4 Palliative Care (W.H.O.) Provides relief from pain and other distressing symptoms; Affirms life and regards dying as a normal process; Intends neither to hasten or postpone death; Integrates the psychological and spiritual aspects of patient care; Offers a support system to help patients live as actively as possible until death; Offers a support system to help the family cope during the patients illness and in their own bereavement; Uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated; Will enhance quality of life, and may also positively influence the course of illness;

5 Pediatric Palliative Care (W.H.O.) Palliative care for children is the active total care of the child's body, mind and spirit, and also involves giving support to the family. It begins when illness is diagnosed, and continues regardless of whether or not a child receives treatment directed at the disease. Health providers must evaluate and alleviate a child's physical, psychological, and social distress. Effective palliative care requires a broad multidisciplinary approach that includes the family and makes use of available community resources; it can be successfully implemented even if resources are limited. It can be provided in tertiary care facilities, in community health centers and even in children's homes.

6 National Consensus Project 8 Domains of Care that provide the guidelines for quality palliative care programs. Domain 1. Structure and Processes of Care Domain 2. Physical Aspects of Care Domain 3. Psychological and Psychiatric Aspects of Care Domain 4. Social Aspects of Care Domain 5. Spiritual, Religious, and Existential Aspects of Care Domain 6. Cultural Aspects of Care Domain 7. Care of the Patient at End of Life Domain 8. Ethical and Legal Aspects of Care

7 MaineHealth Care At Home Daily census of Pediatric daily census of patients. Geographic coverage York, Cumberland, Knox, Lincoln, Waldo, and parts of surrounding counties. Divided into 3 divisions. York, Cumberland And Coastal. Thriving telehealth program. Thriving specialty programs. ie: wound care, cardiopulmonary, maternity/postpartum/pediatrics Full service therapy for the age spectrum. (PT, OT, SLP, nutrition) CNO certified in palliative care and hospice Pediatric Clinical Manager certified in pediatric palliative care and hospice

8 Palliative Care at MHCAH Began in the pediatric realm. Trained the entire pediatric staff to start. Coordination and collaboration with MMC/BBCH and their palliative care physician who did both pediatrics and adults. Continued this close relationship and became involved at a systems level with palliative care leadership and work groups. Identified champions and clinicians who had a desire to be on a palliative care team. Hired several certified clinicians. Began initial education of staff around palliative care.

9 Palliative Care at MHCAH (Cont.) Full participation of Social Work discipline. Interest from all disciplines. Some work with the Chaplaincy Institute of Maine to utilize student chaplains and volunteers to offer support around the spiritual domain. Full buy in from administration and commitment to supporting a palliative care team within the agency. Dedicated Interdisciplinary meetings. Every 2 weeks the team meets to go over cases and review plans of care. An educational component will be added to that meeting as well. Certified Nursing Staff CHPN/CHPPN Multiple Staff trained in Serious Illness Conversations

10 Program Growth If you ve seen one palliative care program, you ve seen one palliative care program. Multiple templates and models for development. Multiple timelines 20 years ago we were making the case, now we are providing data and making the case. Common theme among most programs is that development takes 5-10 years. During that time there are advances and setbacks. Important to always know who the champions and committed are and keep the torch lit.

11 Opportunities. Dignity and Respect - Patient and family knowledge, values, beliefs and cultural backgrounds are incorporated into the planning and delivery of care. Information Sharing - Patients and families receive timely, complete and accurate information in order to effectively participate in care and decision-making. Participation - Patients and families are encouraged and supported in participating in care and decision-making at the level they choose. Collaboration - Patients and families collaborate in policy and program development, implementation and evaluation; in professional education, as well as in the delivery of care. IHI: Partnering with Patients and Families to Design a Patient- and Family-Centered Health Care System: A Roadmap for the Future

12 Strategies for Collaboration with Providers Partner with select providers Promote your agency Create custom materials Collaborate with all members of the health care team Educate others about what you do Create a referral communication system 12

13 Mitchell Mortality Study The Surprise Question

14 Our Work EPIC 18 months experience Mapping OASIS to MDS/Mitchell data fields Analyst reports retrospectively Previous 30 days SOC/Re-certifications 14

15 MDS & OASIS compared MDS OASIS ADL Score 28 Male A800 M0069 Cancer I0100 M1020/M1022 The need for oxygen therapy O0100 (C) M1410 Congestive Heart Failure I0600 M1020/M1022 Shortness of breath J1100 M1400 No more than 25% of food eaten at most meals Section K An unstable condition A1800/Section I M1033/M1034 Bowel incontinence H0400 M1620 Bedfast G0110 M1850 Older than 83 years A0900 M0066 Not awake most of the day 15

16 Our Results 16

17 Our Results 15-28% per month 30-60% move to Palliative Care 10-20% move to Hospice within 6 months 6-10% Palliative Care 17

18 Our Future Plans Edit the data collection to include BMI (2017 OASIS) as proxy for appetite 2018 Begin Surprise Question data collection Begin prospective application of Mitchell assessment to encourage Critical Conversations 18

19 6 month Status Report October 15, April 15, 2016 Readmission Rates for patients on program» Heart Failure 1%» COPD 2% Maine readmissions are 16.6%, 16% nationally (Medicare Home Health Compare 2016) 19

20 MHCAH Tele-palliative care is keeping patients where they want to be HOME 20

21 Who Can Benefit? Cardiac Heart Failure AF Pulmonary COPD Asthma Palliative Care Symptom Management Caregiver Support Pediatric Newborn/Mom Support Acute Illness for infants and children Wound Care 21

22 THANK YOU QUESTIONS? Greg Burns Bob Abel