Transcript Enter Title Here - Cynosure Health

Today’s Webinar will begin at 11:30AM
6/27/12
Introduction
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Peg Nelson, NP, ACHPNachpn
Director of Palliative and Pain Services
St. Joseph Mercy Oakland
Our Palliative Care
Joint Commission Journey
Peg Nelson, NP, ACHPN
Director Pain and Palliative Care Services
The Journey of Creating
Peace and Healing at SJMO
Began in late 1990s when we were attempting
resuscitation on 60-70% of the patients who died
 Only could find 30% patients with any pain
scores at all documented
 Of those we could find – average pain score
when palliative care was consulted: 8/10.
 Demerol was number one drug used for pain
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First Work
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Understanding the suffering at SJMO
Learning from hospice, ethics and local palliative
programs
Institute of Medicine (IOM) Report on End of Life
Institute of Healthcare Improvement
SUPPORT Trial
Mercy Supportive Care
est. 1999
MSN and oncologist
 Harpist
 Healing touch practitioner
 Lots of nurses, case managers and an administration
who supported palliative care and pain management
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Key Processes to Achieve Goal
Assess and understand the suffering.
 Educate, develop and inspire staff and
volunteers to deliver excellence in pain and
symptom management, ethics, palliative and end
of life care management.
 Create systems of care across the continuum that
make it easier to deliver quality care and
support staff and volunteers who deliver care.
 Create access for all who are suffering.
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TOTAL BODY MODEL FOR SUCCESSFUL PALLIATIVE
SERVICES at SJMO*
Head:
Knowledge, Competence
*Conscience:
“Know what to do and the right thing to do”
Hands:
Process, Systems
*Culture:
“How to do it
so all are served”
Heart:
Compassion, Humanity
*Presence:
“Doing it with
enduring love”
Trinity Health Vision for Palliative Care
In Trinity Health everyone impacted by illness will have
access to comprehensive palliative care and experience
care excellence through the prevention and relief of
physical, emotional, social and spiritual suffering.
Compassionate and holistic care will be provided
throughout the journey of living and dying.
We Studied Our Own Experience
Through family post-death interviews
 Staff assessment of the patient and family dying
experience and their own suffering and needs
 Post-death chart review
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Our Response
Created a new culture, where suffering is not
acceptable with focus on continuous improvements
in patient care.
 Provide 24-hour pain, palliative and spiritual
support for patients and their families.
 Provide team members (staff and volunteers) with
the training and tools necessary to provide
excellence in end of life care.
 Multiple entry points for receiving pain and/or
palliative and/or hospice care.
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Interventions
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Required 5 hour pain/palliative class
Extensive resident and nurse end of life education
Comfort Care order sets
Mentoring staff
One patient at a time – the world and culture changed
Pain Scores
At time of consult for palliative care:
 2000 – 7.8/10
 2001 – 6.3/10
 2004 – 3.4/10
 2005 – 2.4/10….and continues to this day
Which was one of the biggest reasons we won the
Circle of Life Award in 2006
COMFORT CARTS
“Crash Carts for the Dying”
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CD Player and many CD’s
• Hand Casting Materials
Bibles, Korans
• Love Blankets
Example of Prayers
Grief Information
“This is a love blanket, it is a symbol
Funeral Home Listings
of the love shared in ____’s life.
Information on physical,
We hope it brings him comfort now
emotional and spiritual
and after he dies please take it
with you and may it help you in
changes at end of life
the days to come.”
• Sympathy cards/Dove Sign
for Door
Creation of a loving and peaceful
environment – we call sacred space
Early Milestones
CALL CARE Project – Supportive Care of the
Dying Coalition – one of 11 sites in 2001 funded
by Robert Wood Johnson – to implement
palliative outpatient services
 $150,000 donation from family of patient to
expand services - 2002
 $200,000 Trinity Health Mission grant to expand
palliative care services for the poor in Pontiac
2005
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Comfort Companions
Common top two fears people have at end of life are:
 Pain not being controlled
 Dying alone
Our Comfort Companion Program helps to ease these
fears by:
 Providing a loving presence for patients.
 Providing support and respite for families.
 Assurance that patients are safe from distressing
symptoms.
Comfort Companions Bring:
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Presence
Kindness
Assurance of physical and
emotional comfort
Notifies staff if needs arise
Communicates with
family
Soothing Environment
Sensitivity to culture and
spiritual needs
Love
Since 2005, 468 patients served, and over 9824 hours of service
Bedside Sacred Ritual in Ambulatory Surgery
Life in the Emergency Department
and death
Palliative Care Team
NP Director*
 Medical Director*
 Bereavement/Volunteer
Coordinator
 Nurse Practitioners*
 Music
Practitioner/Harpist
 Healing Touch/Massage
Therapist
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*Palliative Board Certified
Chaplain
 Respiratory Therapist
 Case Manager
 Dietician
 Pharmacy
 Wound/Ostomy Nurse
 Utilization Review
 Homecare/Hospice
 Oncology Nurse
 Social Work
 Internal Medicine
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We aspire to meet the National Consensus
Project’s clinical guidelines for quality
palliative care.
And use CAPC tools and consensus
recommendations
8 Domains of Quality Palliative Care
1.
2.
3.
4.
5.
6.
7.
8.
Processes and Structure of Care
Physical Aspects of Care
Psychological and Psychiatric Aspects of Care
Social Aspects of Care
Spiritual, Religious and Existential Aspects
Cultural Aspects of Care
Care of the Imminently Dying
Ethical and Legal Aspects of Care
We are seen as the pain and
palliative care team
Reason for consultation:
 40% physical and psychological symptom
management
 40% Clarification of goals, advance care planning,
family support and communication
 20% End of life, withdrawal of life support and
transition to hospice
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Practical Aspects
Scattered-bed Consultation Service
(Oncology/palliative unit sees most expected end
of life)
 24/7 with weekly team meetings
 Typical Social Worker role is shared by Unit
based case manager, social work, unit RN and
palliative clinicians.
 Oversight by Pain Steering committee which
reports to Medical Staff Quality and the Quality
and Safety Board of Directors
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Palliative Care Snapshot
(one month – 31 patients)
Primary Diagnosis
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Cancer – 38%
Heart Disease – 19%
Respiratory – 16%
CVI – 10%
Kidney – 6%
HIV/sepsis/other – 11%
Disposition
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34% hospice
19% home
15% ECF
3% rehab
29% died
Palliative Care Snapshot
(one month – 31 patients)
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ICU LOS – 22% (median 3 days, only 1/31
had LOS >7 days)
Hospital LOS – range 2-61, median 7 days
LOS on service – range 1-36, median 4 days
Race
83% White, 13% Black, 4% Hispanic
Palliative Care Service
Palliative census – range 2 to 10 per day (average 5)
(NP bills 110-190 visits/month), average 32 palliative
consults/month
 Referrals for bereavement support, comfort
massage, No one dies alone support, life review
assistance, chaplain and healing touch can be
ordered by RN
 Consultation for goal clarification and/or symptom
management ordered by physician
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Of Patients who died
All died in private room
 One patient died alone
 Pain score before death – average <1/10
 Range 0-3/10
 No patients had CPR at death
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Expense/Cost Avoidance/Revenue
Total Expense $540,000/year
 FTE’s 4.8
 Cost Avoidance based on CAPC impact calculator –
$920,000* (based on volume we are more productive
than most mature programs)
 Revenue
 NP billing: $230,000 - $99,000 = $131,000
 Donations: $11,390
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Current Performance Measures
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Spiritual Assessment (Process and Outcome)
Non-pain symptom assessment (Process)
Pain reduced to 4/10 or acceptable level in 24 hours
(Outcome)
Family was given appropriate information in order
to make decisions regarding loved one (Outcome)
(Previous outcome for family – felt patient died
comfortably and felt supported)
Quality Metrics
100
90
80
70
60
50
40
30
20
10
0
Nonpain
Spirituality
Pain <4
June
Sept
Nov
12-Mar
Commitment to Support of Others
– since 2005 we have mentored:
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131 Hospitals, ECFs, hospices and corporate/health
systems
64 individual Clinicians
81 new No One Dies alone programs
>2200 clinicians attended pain/palliative classes
30 churches and over 300 parish nurses
9 Colleges/Universities
Keys to Successful Certification
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Mature Palliative Care Program
Experienced Clinical Leader/Director
Experienced Medical Director
Senior Leadership Support
Certification in Palliative Care – hospital
priority
Documents Prepared
• Developed written ‘Scope of Practice’
• Performance Improvement Plan –
formalized in 2011
• Performance Measures Submitted
• Education binders based on domains
• Team orientation manuals
• End of Life/Bereavement Policy
Lessons Learned
• Rehearse Tracers/Mock surveys were helpful
• Speak as an interdisciplinary team, the survey
will be team focused
• Prepare and demonstrate 4 months of data
for review at survey
• Focus on National Consensus Guidelines,
CAPC, or National Patient Safety Foundation
• Utilize published tools and resources
• Imperative to disseminate educational
materials
Lessons Learned
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Role of chaplain and social worker
Performed detailed tracers on patients
Job descriptions for practitioners
Scope of practice shared among
members
• Non-pain assessments and
documentation of assessment
Resources
• The Joint Commission Disease Specific
Certification Guide
http://www.jcrinc.com/AccreditationManuals/PCC12/4032/
• Center to Advance Palliative Care
http://www.capc.org/about-capc
• National Consensus Project
http://www.nationalconsensusproject.org/
Resources
Center to Advance Palliative Care
Palliative Care Consultation Service Metrics:
Consensus Recommendations
http://online.liebertpub.com/doi/pdfplus/10.1089/
jpm.2008.0178
CAPC Certification Guide
http://www.capc.org/palliative-care-professionaldevelopment/Licensing/joint-commission/tjcguide-2011.pdf
Resources
The Joint Commission (TJC) Advanced
Certification for Palliative Care
Programs
http://www.capc.org/palliativecare-professionaldevelopment/Licensing/jointcommission
Peace and healing is sacred
Contact information:
Peg Nelson 248.858.3399
[email protected]
Notes will be on our website
Thanks for joining us today!