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Hospice in LTCF and AL

VIEWS: 1 PAGES: 16

									                                                                     9/29/08





     Hospice in LTCF and
     AL: Who Does What?


      Presented by Lores Vlaminck, RN, BSN, MA, CHPN




                                                                "




                About….

  Lores Vlaminck, RN, BSN, MA, CHPN
      Independent Consultant, Lores Consulting
      32 years nursing experience in critical care, outpatient,
       home care and hospice
      ELNEC Trainer
      Hospice MN Board Member-Executive Committee
      MHCA Nurse Consultant
      Senior Consultant, Pathway Health Services
      Grandmother of 4 WONDERFUL grandchildren!

9/29/08                           2




                         Objectives

      Describe bridges to enhance and encourage hospice
          and home care staff collaboration in care provision
          for their common client.

      Explore the barriers to communication and
          collaboration between hospice and home care staff. 

      Explore tools that identify specific roles of the
          hospice and home care staff, and family and friends
          in caring for a terminally ill patient and family.




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                                                                     9/29/08





                      Acronyms

•  Center for Medicare and Medicaid (CMS)
  •  Certification for Hospice
  •  Conditions of Participation (CoP’s)
     •  Payment for Hospice

•  National Hospice and Palliative Care (NHPCO)

•  National Home Care Association (NAHC)




                     Definitions

  Hospice
    Hospice offers a comprehensive program of care to patients
     and families facing a life threatening illness. Hospice is
     primarily a concept of care, not a specific place of care

  IDG (Interdisciplinary Group)
    Core team of professionals that meet regularly to develop and
     review the plan care. The team members include at a
     minimum; physician (medical director/attending, registered
     nurse, social worker, chaplain/counselor)




    Regulations LTCF, AL, and
    Hospice Have in Common

•  Nurse Practice Act
   –  Applies to nursing practice in all settings,
   –  In coordination with requirements of LTCF,
      hospice, or home care licenses
•  Vulnerable Adult Act
   –  Applies to all health care providers, including
      hospice and home care




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                                                        9/29/08





  Pertinent Nurse Practice
         Act Issues
  Iowa Board of Nursing
    RN Assessment
    LPN Role
    Unlicensed Staff
    Delegation and Supervision




        Barriers and Challenges
            Across Settings
  •    Patient’s complex medical needs
  •    Continuity of care
  •    Coordinated care plan
  •    Need for 24-hour per day caregiver (family)
  •    Education and comfort level of staff
  •    Financial resources for level of care required
  •    Communication, supervision, regulations
  •    Expectations of patient and family
       •  Financial burden
       •  Personnel strain




       Barriers in Communication and
                 Collaboration

  Different Sets of Rules and Licenses/
  Conditions
  Agency/Facility Policies and Philosophies

  Competition

  Time

  Personalities




                                                              3

                                                              9/29/08





  Collaboration SNF + Hospice




   Responsibilities of Providers
                   Nursing Services


       SNF                            Hospice
                             
   RNcoordinates hospice plan

   Provides care 24/7 as
                             of care, makes intermittent
  with all SNF residents     visits, educates staff and
                             families on physical changes

   Supervises the day-to-
                             and interventions, and
  day care provided by       updates care plan
  SNF staff (dietary,
  housekeeping, nursing,     
   Supervises assigned HHA
  personal cares, etc)




   Responsibilities of Providers
                  Physician Services


     SNF Primary MD              Hospice Medical Director

   Resident’s primary           Provides resource for
    MD and LTCF’s                 palliation and
    medical director              treatment of physical
    continue to follow            symptoms
    resident




                                                                    4

                                                                            9/29/08





  Responsibilities of Providers
                        Social Services


               SNF                                Hospice
  Collaborates with hospice           Provides support in
   social worker for resident/          discussion of end of life
   family care conferences              care decisions, choices,
                                        advance health care
  Communicates with                    planning
   hospice social worker               Initiate and facilitate
                                        patient/family care
                                        conference




  Responsibilities of Providers
                   Chaplain/Counselor


               SNF                                Hospice

  Communicates end of                 Provides assessment
   life care needs of                   and support of
   resident and family to               spiritual, nutritional,
   hospice                              emotional needs
  Participates in care                Initiates
   conferences as needed                communication with
                                        patient/family as
                                        assessed




  Responsibilities of Providers
                 Personal Care/Dietary


               SNF                                Hospice
  Provide routine personal cares,     Provide intermittent visits for
   assistance with ADL’s, feeding,      personal care, performance of
   transferring, etc                    nursing delegated tasks, respite,
                                        etc.
  Prepare and provide nutrition
   and supplements as indicated




                                                                                  5

                                                             9/29/08





       Hospice Referral Process
                        SNF Staff



•  Identify
                              2         •  Contact
   potential         •  Obtain MD          hospice of
   hospice              order              resident’s
   patients                                choice

           1                                       3




Hospice Admission Process
                      SNF Staff, cont.




   Provide hospice
                               5            Evaluate the
        with              Assist to        need for MDS
   documentation         coordinate           reassess
                        introduction
                         and admit
               4                                    6




      Hospice Intake Process
                     Hospice Staff




   •  Review
                               2           •  Contact MD
      resident         •  Assess to            to review
       record              confirm            plan of care
                          eligibility
                                                        3
           1




                                                                   6

                                                            9/29/08





Hospice Admission Process
                  Hospice Staff, cont.




     Review            Obtain             Notify SNF of
     hospice        signatures for       hospice election
  services with                          Coordinate care
                       election
                                              plan
 patient/family
         4                   5
                                                  6




        SNF Plan of Care




Assisted Living Plan of Care




                                                                  7

                                    9/29/08





   Hospice Plan of Care




  Integrated Plan of Care




      Physician Orders


  Policy and protocol for orders

  Attending MD role

  Medical director role




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Medical Record Management

                              Hospice
                               documentation
                              Care plan
                              Copies
                              Discharge records




Utilization of Therapy Services

  Physical Therapy

  Occupational Therapy

  Speech Language Pathology

  Music Therapy

  Massage Therapy

  Other




             Hospitalization and
              Emergency Care


                                           Hospice
                                         coordinates
                      Related to           transfer
                   Terminal Illness
                                      Hospice follows
 Emergency                             to inpatient

                                             SNF
                    Unrelated to
                                         coordinates
                   Terminal Illness
                                           transfer




                                                              9

                                                         9/29/08





Communication Regarding…


                         Revocation


                         Transfer


                        Discharge




         Communication
       Responsibilities at the
          Time of Death
 Determine in advance who is responsible for
 notifying the physician, pharmacy, mortuary,
 and coroner




   Skilled Nursing Facility


                       SNF Staff

                           Provide
     Notify hospice      support to       Determine
      of imminent     patient/family,      who will
          death       staff and other   contact family
                          residents




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                                                           9/29/08





              Assisted Living


                         SNF Staff

                             Provide
       Notify hospice      support to       Determine
        of imminent     patient/family,      who will
            death       staff and other   contact family
                            residents




                        Hospice


                            Provide       Offer to visit
       Make visit to      counseling,       at time of
       dying resident    spiritual and     death, assist
         as needed         volunteer           with
                            support       arrangements




     Skilled Nursing Facility


  Medication disposal

  Post death protocol- body release

  Notifies SNF staff and residents of death and
  subsequent plans




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                                                                 9/29/08





                       Hospice


  Determine family needs for support

  Attend visitation/funeral as determined

  Provide support to SNF staff and residents




       Regulatory Expectations

   Integration of the plan of care


   Collaboration


   Identification of SNF and Hospice responsibilities




                 Best Practices


  Relationships between LTCF and Hospice that are built on
  mutual respect and trust, enhance communication that can
  improve the quality of end-of-life care

  Collaborative efforts and interventions decrease acute care
  admissions




                                                                      12

                                                                 9/29/08





Tools to Enhance and Encourage
          Collaboration




               Bridge Building

•  Identify and agree upon barriers

•  Exchange information on limitations of each program,
  identify gaps, staffing issues, regulatory requirements and
  limitations

•  Discuss financial impacts of additional nursing visits/
  delegation of tasks

•  Identify services and potential for duplication due to home
  care and hospice licensure




        Tools to Build Bridges

•  Face-to-face introduction
•  Meetings to build relationships
•  Telephone
•  Identify primary staff (Class A and Hospice)
•  Identify method of communication
•  Hospice invite HC to IDG (by phone or in person)
•  Share health-related information as appropriate




                                                                      13

                                                                     9/29/08





Shared Health-Related Information


 •  HIPAA-Confidentiality and Release of Information Forms

 •  Hospice Conditions of Participation (CMS) 12.2.2005

     e) Hospice must develop and maintain a system of
   communication and integration
      •  Ensure the IDG maintains responsibility for directing/
         coordinating/supervising the care and services
      •  Provide on-going sharing of information with other
         non-hospice healthcare providers furnishing services
         unrelated to the terminal illness and related conditions.




        Points for Clarification

  Medication Storage and Dispensing

  Medication Administration/Charting

  Changes in Medications or Treatment Plan

  “PRN” medication orders

  Who “supervises” who?

  Access to patient care plan and chart




Scenario of Changes in Medication or
       Treatment Plan in AL




                                                                          14

                                                           9/29/08





        Tools to Identify Roles
  •  Written
     Agreement/
     Contract
  •  Algorithm for
     Communication
     and Intervention
  •  Individualized
     Patient Care Plan
  •  Debriefing




                  Conclusion


Family members will always remember the last
days, hours, and minutes of their loved one’s life.
Health care staff have a unique opportunity to be
invited to spend these precious moments with them
and to make those moments memorable in a
positive way.




                   References

      CMS State Operations Manual (SOM) Appendix P -
      Survey Protocol for Long Term Care Facilities in
      part: (Rev. 26, 08-17-07)
        http://www.cms.hhs.gov/manuals/downloads/
         som107_Appendicestoc.pdf
      Promising Practices for Implementing the Medicare
      Hospice Benefit for Nursing Home (NH) Resident
        http://www.cms.hhs.gov/
         SurveyCertificationGenInfo/downloads/
         SCLetter02-29.pdf




                                                                15

                                                          9/29/08





               Lores Vlaminck, RN, BSN, MA, CHPN
                3063 Darcy Drive NE, Rochester, MN
                               55906
                        507.288.6050 (office)
                         507.358.4301 (cell)
                      Email: Lores@charter.net




46   9/29/08
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