Transcript Document

END-OF-LIFE CARE:
Module 6
Venues & Systems of Care
http://www.growthhouse.org/stanford
Module #6
Work Rounds Vignette
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Module #6
Learning Objectives
• Describe venues for ELC
• Navigate across care systems to meet needs of
patient and family
• Utilize strategies for making system changes
within your own institution
• Incorporate this content into your clinical
teaching
http://www.growthhouse.org/stanford
Module #6
Outline
• Venues for ELC
– Hospice
– Acute care
– Subacute care
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Enlisting resources
Break
Strategies for change
System change within your institution
Conclusion and goals
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Module #6
What exactly is hospice?
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Myths of Hospice
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A place
Only for people with cancer
Only for old people
Only for dying people
Can help only when family members are able to provide
care
For people who don’t need a high level of care
Only for people who can accept death
Expensive
Not covered by managed care
For when there is no hope
(Naierman, 1998)
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Realities of Hospice 1-5
1. About 80% of hospice care takes place in the
home
2. Hospices are increasingly serving people with
the end-stages of chronic diseases
3. Hospices serve people of all ages
4. Hospice focuses as much on the grieving
family as on the dying patients
5. Alternative locations or resources may be
available
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Realities of Hospice 6-8
6. Hospice is serious medicine, offering state-ofthe-art palliative care
7. Hospices gently help people find their way at
their own speed
8. Hospice can be far less expensive than other
end-of-life care. Most people who use hospice
are over 65 and entitled to the Medicare
Hospice Benefit, which covers virtually all
hospice services
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Realities of Hospice 9-10
9. MCO’s are not required to include hospice coverage, but
Medicare beneficiaries can use their Medicare Hospice
Benefit any time, anywhere they choose. Those under
65 are confined to the MCO’s services, but are likely to
gain access to hospice care upon inquiry
10. Hospice helps families see how much can be shared at
the end of life through personal and spiritual
connections; many family members look back on their
hospice experience thankful that everything possible was
done toward a peaceful death
Naierman, 1998
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Module #6
The Modern Hospice
Movement
• In the 1950s, as medical technology developed, most
people died in hospitals. The medical profession
increasingly saw death as a failure.
• Physical pain associated with terminal illness was not a
target of treatment.
• Dame Cicely Saunders, MD, founded St. Christopher’s
Hospice in London in the 1960s, in an effort to discover
practical solutions to alleviating human suffering.
• She introduced hospice in the U.S. in a lecture at Yale in
1963. This contact set off a chain of events which
resulted in the development of hospice care as we know
it today.
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Module #6
Hospice is...
• (Not necessarily) a place
• A philosophy of care
• A structure for care
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Brainstorm
• What problems do you encounter in trying to
refer patients to hospice?
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Comparing Hospice and
Standard Home Care
Hospice
Standard Home Care
Comprehensive, total care
Task-oriented care
Medications related to terminal illness
covered
Medications not covered
Staff on call 24 hours
Scheduled visits
Support for family
Patient care only
Bereavement support
No bereavement support
Physician care not covered (except
Medical Director)
Physician care not covered
Prognosis-based eligibility
Home-bound, skilled care need
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Medicare Hospice
Eligibility Requirements
• Medical director and attending physician must
attest to eligibility
– Terminal illness
– Prognosis < 6 months
• Patient accepts palliative care
• Hospices may also refuse to admit a patient if
they have inadequate caregiver support at home
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Brainstorm
Returning to the vignette we started out with and
using this information about hospice:
What do you need to know about Mr. Young to see
if hospice would meet his needs?
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Medicare Hospice Financing
• Reimbursement on a per diem basis
• Emphasizes care at home
• Brief acute care and 5-day admits are possible
• Continuous care
• If nursing home care is needed, hospice can
continue there
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Steps to Making a Hospice
Referral
• Identify whether patient meets eligibility
standards
• Discuss goals of care with patient and family
• Negotiate about specific needs
• Activate referral mechanism
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Hospice is Not Appropriate
for Every Patient
• Too sick to leave the ICU
• If residential hospice is not available:
– Homelessness
– No caregiver available at home
• Not old enough for Medicare
• Needs more skilled care
• Doesn’t accept that he is dying
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Precepts of Palliative Care
• Respecting patient goals, preferences, and
choices
• Comprehensive caring
• Priority on comfort
• Utilizing the strengths of interdisciplinary
resources
• Acknowledging and addressing caregiver
concerns
• Building systems and mechanisms for support
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Module #6
Options for Dying in Acute
Care
• Consultation teams
• Designated beds
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What You Can Do if Patient
is Imminently Dying
Medical support
– Inform discharge planner
– Shift focus to quality of life
– Review medications
System support
– Take opportunity to change mind-set to palliative-oriented acute
care
– Find other allies
Social support
– Involve the family
– Involve the team in the family’s support
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Extended Care Options
• Subacute unit
• Nursing home or skilled nursing facility (SNF)
• Rehabilitation unit
• Residential care facility
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Subacute Unit
Strengths
• Higher staffing ratio than
in nursing home or SNF
• More complex care
• Many people see ELC as
subacute level care
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Weaknesses
• Discharge planner may
not be aware of such a
unit in your community
• May see their focus as
being on rehabilitation
• May not specialize in ELC
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Nursing Home or
Skilled Nursing Facility
Strengths
• Most Medicare will follow
patient for 2 months after
acute admit
• Hospice could follow
• Recognized as
appropriate for long-term
care
• Some specialize in ELC
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Weaknesses
• Variation in quality
• Lower staffing ratio
• May not provide ELC
• May not be able to provide
technologically complicated
care
• Aversion of many people to
nursing homes
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Rehabilitation
Strength
Weakness
• Appropriate if there is a
concrete rehabilitation
goal
• If patient has no
rehabilitation potential,
can lead to sense of
failure & discouragement,
loss of hope
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Residential Care Facilities
(Assisted Living)
Strengths
• Excellent option if facility
has experience &
willingness
• Number of facilities is
growing
Weaknesses
• Requires hospice waiver
• State laws may restrict
availability of hospice in
assisted living facilities
• Funds for care and
caregiving must be
available
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Inpatient Hospice/Palliative
Care Wards
Hope for the future
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Brainstorm
• If an extended care option were appropriate for
Mr. Young, what further information would you
need, to be able to match his needs to what is
available?
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Module #6
What You Can Do
• Find out about extended care options in your
community that specialize in ELC
• Talk with your home hospice people – who do
they have contacts with in SNFs and nursing
homes?
• Facilitate a family conference
• Enlist other resources
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Module #6
Enlisting Resources
• What resources might be available in your
community that you are currently not utilizing as
well as you might?
• Within your system
• Within the community
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Module #6
Continuum of System Change
• Macro-changes
e.g., improve reimbursement system
• Local system change
e.g., how your institution works
• Micro-changes
e.g., different physician behaviors provide an incentive
for others to change
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Module #6
Quality of ELC at the Local
System Level
• Given the strengths and weaknesses of your
institution, what kinds of changes would you like
to see in this system, to improve care of the
dying?
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Module #6
A Strategy for Change
• Assess priorities
• Assess feasibility
• Obtain buy-in
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Module #6
Key Ways to Obtain Buy-in
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Find allies
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Build networks
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Build on strength
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Avoid major barriers
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Appeal to the good
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Measuring Change…a Powerful
Tool in Effecting Change Itself
• Allows people to see what has been accomplished
• Creates tension to promote buy-in
• Facilitates adjustment to improve results
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Three Ways to Measure
Change
• Calculate numerator/denominator
• Collect pre/post data
• Benchmark against a standard
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Module #6
Promoting the Cycle of Change
• To keep the cycle of improvement going, how
might we insure that positive change is
recognized, and peoples’ efforts rewarded?
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Module #6
In Your Institution,
Where Can You Make
a Difference in ELC?
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Education
Pain
Non-pain symptoms
Psychosocial aspects of
care
• Spiritual aspects of care
• Decision making
http://www.growthhouse.org/stanford
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Ethics
Communication
Awards
Venues of care
Research
‘By next Tuesday’
Spontaneous changes
Module #6
Learning Objectives
• Returning to the vignette we started out with and
using this information about hospice:
• Describe venues for ELC
• Navigate across care systems to meet needs of
patient and family
• Utilize strategies for making system changes
within your own institution
• Incorporate this content into your clinical
teaching
http://www.growthhouse.org/stanford
Module #6