Transcript Improving Advance Care Planning

South Carolina Association for
Healthcare Quality
July 13, 2007
Tamra N. West
Director of SC Programs
The Carolinas Center for Hospice and End of Life Care
The Carolinas Center
for Hospice and End of Life Care
• Two State Association
• Technical Assistance and Support
for hospice and end of life care
coalitions
• End of Life Care Initiatives
• “Helping every community live &
die well”
Advance care planning
Hospice care
Palliative care
Bereavement care
Hospice Care
in the Carolinas
Hospice 101
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Goal is palliative rather than curative
Not necessarily a “place”
Unit of Care is the patient/family
Interdisciplinary Team –RN, SW, CNA, MD,
Chaplain, Therapists, Volunteer, Bereavemen
Counselors
Six months or less if disease runs its normal
course
Wide range of diagnoses – not just cancer
Is available in every county in SC
Care provided at “home” and in other
settings as needed
Hospice 101 (continued)
• Four levels of Care – routine, general
inpatient, inpatient respite and continuous
care
• Paid per diem for all except continuous care
• Per diem covers staff, related drugs, supplies
and equipment, therapists and bereavement
services after death
• Beneficiaries ELECT the hospice benefit and
waive other services for the terminal illness –
only the beneficiary can revoke and
discharges should be minimal
• Paid for by Medicare, Medicaid, private
insurance
• Hospice must serve without regard for pay
source (or lack of)
SC Hospice Data (2006)
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81 licensed sites; 61 different providers
8 hospice facilities, 132 beds
Available in all counties – avg. 7 per county
CON for facility only
64% for-profit, 46% not-for-profit
75% freestanding, 16% hospital based
Approx. 50% are accredited, all are licensed,
all but 1 are certified
In 2006, SC Hospices :
• Served over 120,000 patients
• Served approx. 250,000 family members
• Provided almost 1.5 million days of care –an
increase of almost 400,000 days from 2005
• Provided 23,000 days of care in hospice
facilities
• Provided care to over *4,700 residents of
nursing homes (*2005 data)
Hospice Patient Data 2006
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70% admitted at home, 16% in NH, 6% in hospital
75% White, 23% African American
89% Medicare, 5% Medicaid, 4% Private Ins
41%/59% Cancer to Non-Cancer diagnosis (44/56
in 2005 and 60/40 in 2001)
• ALOS 89 days, median LOS 33 days
• 29% died < 7 days, 13% died > 180 days
• 62% died at home, 16% in NH, 10% in hospice
facility, 9% in hospital
Why A Hospice Quality Initiative?
• Current national landscape pointing toward a
Hospice Compare
• National and local concern about variability of
hospice care
• CMS Focus on Quality, Accountability, and Public
Disclosure
• New Conditions of Participation expected in May
2008 (first revision since 1983)
• To improve patient care – “to measurably show
organizational excellence and demonstrate
improvement efforts across all aspects of hospice
operations and care”
Changing Focus of Proposed
Hospice CoPs
Past Focus
• Ensuring that Medicare certified facilities
met the structural and procedural
standards for patient health and safety
Changed Focus
• Patient centered
• Emphasizes quality improvement and
patient outcomes (QAPI requirements)
Proposed Standards for Hospices
“The hospice must develop,
implement and maintain an
effective, ongoing, hospicewide, data-driven quality
assessment process
improvement program”
QAPI Standards (Standards 1 and 2)
• Program Scope
• Measure quality (including adverse
events) and operations
• Measurably improve palliative
outcomes and EOL support
• Program Data
• Drive QAPI with data
• Monitor and ID opportunities for
improvement
• Timing and detail determined by
governing body
QAPI Standard (Standard 3)
• Program Activities
• Consider incidence, prevalence,
severity
• Address and prevent adverse events
• Focus on high risk, high volume,
problem prone areas
• Improve and monitor over time
QAPI Standards (Standards 4 and 5)
• Performance Improvement Projects
• Reflect scope and complexity of hospice
• Document what, why, and how successful
• Executive responsibilities
• Define, implement, and maintain QAPI
• Address quality and patient safety priorities
• Set patient safety expectations
Past Hospice Quality Focus
• Hospices have historically relied on anecdotal
evidence, less focus on outcome data
• Good death + Happy family= Quality
• Most currently do chart reviews, collect and
review program data, collect feedback from
family and referral source via surveys
• Many participate in current state and national
evaluation efforts
State Efforts
• Collection and reporting of state hospice data
• Benchmarking project – optional participation
offered to members
• Provider-friendly Family Evaluation of Hospice
Care
• 2006 Variability of Care Study
• 2000,2002 and 2004 State Survey on Public
Attitudes about End of Life Care
• 2006 State Pain Survey
• 1997 and 2007 SC DHHS Hospice Patient
Satisfaction survey
National Efforts
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NHPCO National Data Set
Family Evaluation of Hospice Care (FEHC)
Family Evaluation of Palliative Care (FEPC)
Family Evaluation of Bereavement Services
Quality Collaboratives
End Outcomes Project (since 2000)
– Comfortable Dying
– Self-determined Life Closure
– Safe Dying
– Effective Grieving
The New Quality Initiative
Framework
• The National Hospice and Palliative Care
Organization is leading the way with “Quality
Partners: Stronger, Together”
• State organizations and hospice providers and
individuals can be “partners”
• Developed “for hospice, by hospice”
• Provides tools and resources to help programs
assess, monitor and improve care and services
• www.nhpco.org/qualitypartners
Quality Partners is
NHPCO’s national
program to assure that al
hospice provider
organizations deliver
quality care to patients
and families.
Quality Partners Initiative Goals
• To give patients and families the quality
care they deserve
• To decrease variability locally and
nationally
• To foster an industry-wide commitment
to evidenced based standards
• To demonstrate hospice care as the
“gold standard” in end of life care
• To shape and improve end of life care
Quality Partners Ten Components
• Patient & Family
Centered Care
• Ethical Behavior &
Consumer Rights
• Clinical Excellence &
Safety
• Inclusion & Access
• Organizational
Excellence
• Workforce
Excellence
• Standards
• Compliance with
Laws &
Regulations
• Stewardship &
Accountability
• Performance
Measurement
Patient & Family Centered Care
• Providing care and services that are
responsive to the needs and exceed
the expectations of those we serve
Ethical Behavior and
Consumer Rights
• Upholding high standards of ethical conduct
and advocating for the rights of patients and
their family caregivers
Clinical Excellence & Safety
• Ensuring clinical excellence and
promoting safety through standards
of practice
Organizational Excellence
• Building a culture of quality and accountability
within the organization that values collaboration
and communication and ensures ethical business
practices
Workforce Excellence
• Fostering a collaborative, interdisciplinary
environment that promotes inclusion,
individual accountability and workforce
excellence, through professional
development, training, and support to all
staff and volunteers
Standards
• Adopting the NHPCO Standards of Practice for
Hospice Programs and/or the National
Consensus Project’s Clinical Practice
Guidelines for Quality Palliative Care as the
foundation for the organization
Compliance with
Laws & Regulations
• Ensuring compliance with all
applicable laws, regulations, and
professional standards of practice,
and implementing systems and
processes that prevent fraud and
abuse
Stewardship & Accountability
• Developing a qualified and diverse
governance structure and senior leadership
who share the responsibilities of fiscal and
managerial oversight
Performance Measurement
• Collecting, analyzing, and actively
using performance measurement
data to foster quality assessment and
performance improvement in all
areas of care and services
Inclusion & Access
• Promoting inclusiveness in the
community by ensuring that all people –
regardless of race, ethnicity, color,
religion, gender, disability, sexual
orientation, age, or other characteristics
– have access to hospice programs and
services
For Each Component
• Self assessment checklist
• Cornerstone document
• NHPCO Standards, organized by
component
• Resources and tools
• Background reading
• Performance Measures
Self Assessment
• Ability to rate each hospice on a rating scale
• Each component has a checklist
• Based on best practices from NHPCO
Standards
• Ability to enter data into a web-based
interface and get a printed report
Resources and Tools
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Technical materials
Forms, samples, best practices
Links to web resources
Helpful articles
Links to Info Center with a comprehensive
list of journal articles and books
Self-Assessment Reports
• Provide detailed information based on a
five-point scale
• Allows hospices to compare with others in
the state and nationally
• “Traffic light” indicators indicate and
prioritize areas for improvement
– Green, Yellow, Red
Goals for Providers
• Improve care
• Prepare for surveys and accreditation
• Prepare for anticipated changes in
Hospice Conditions of Participation (May
2008)
• Meet the anticipated QAPI requirements
• Build an organization and a team
dedicated to quality
The Carolinas Center Response
• 31st State “Quality Partner” (Aug.2006)
• Encourage providers to become “Quality Partners”
• Deliberately weave “quality” into all current
operations and practices – internal operations, board
of directors, member education, publications, etc.
• Focused education efforts beginning in 2007 and
throughout 2008 for CEOs, boards, frontline staff
• Increase member participation in benchmarking
opportunities
• Convene a 2-State Quality Workgroup/Council to
work through the process at the state level—
assessment, plan, implement
Quality is never an accident;
it is always the result of
high intention, sincere
effort, intelligent direction
and skillful execution; it
represents wise choice of
many alternatives.
William A. Foster
Questions?
Tamra N. West
The Carolinas Center
for Hospice and End of Life Care
803-791-4220
[email protected]