Ann Hablitzel, RN, BSN, MBA Hospice Care of California

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1 Ann Hablitzel, RN, BSN, MBA Hospice Care of California

2 Objectives Describe the creations of new community based palliative care programs Identify criteria for admission Discuss philosophy and goals Analyze outcomes

3 Palliative Care Definition In 2008 as part of the revised Conditions of Participation of Hospice CMS defined Palliative Care as follows: Palliative care means patient and family-centered care that Palliative care means patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social and spiritual needs and to facilitate patient autonomy, access to information, and choice.

4 Implement Palliative Care Program to Manage Implement Palliative Care Program to Manage Targeted Population to minimize ER, IP, and Triage to Hospice, all to reduce unnecessary costs

5 Pilot for 1 Year Case load for this pilot palliative program will be set to 35 members at any point in time. The overall outcome of this pilot program will be to realign members hope with realistic expectation, realizing that some members that are referred to this program will subsequently transfer over to hospice care. Arta Western will secure the services of an established palliative care provider in Orange County

6 Focus of Program To anticipate a member s care needs so that they can and are met in appropriate setting 1. PCP office 2. Home 3. Outpatient setting Clinic Urgent care 4. Only accessing ER or hospitalization when essential and all other measures have failed

7 Overall Goals Improve patient care Improve access to appropriate care settings Reward providers for behaviors consistent with IPA s/caloptima s and State requirements Decrease costs Decrease Efficiency Adjuster impact Facilitate communication, coordination, and hand-offs Pain and symptom management Advance care planning DPAHC

8 Structure and Process Identification of patients who would benefit from Palliative Care Program Develop Criteria for evaluation and admission Develop Criteria for evaluation and admission Referral process Fax sheet MD order Authorization process Letter of explanation - to family (English and Spanish) - to PCP

9 Criteria Chronic end stage conditions which include: Diabetes, CHF, CAD, COPD, and cancer to name a few Other factors may include the following criteria Patient is diagnosed with life-limiting illness Recurrent or metastatic cancer Loss of function after a CVA Advancing dementia ESRD Advanced Cardiac Disease Not a candidate for curative therapy Uncontrolled symptoms Prolonged stay in ICU or hospital without progress or with lifelimiting diagnosis Potential GT / trach procedure

10 Interdisciplinary Team Based Care Communication Provide purpose and explanation of Palliative Program to Provide purpose and explanation of Palliative Program to Clinical Team focus on communication, authorization process and utilization of resources

11 Meaningful Clinical Response Nursing Availability by Phone RN on call 24/7 who provides triage and has access to patient/family information Additional RN and LVN available 24/7 to do patient home visit if needed Admissions can be scheduled 7 days a week Patient Symptom Crisis Management Established protocols which are disease specific Additional RN and LVN available 24/7 to implement crisis management team response and assess degree of responsiveness to treatments Will revisit and document goals of treatment consistent with patient and family wishes

12 Integrated Medical and Social Supports Practical Matters access to transportations Community resources Concurrent Care Services are available

13 Outcome Data Data Collected Demonstrating Cost Avoidance or Improved Resource Utilization Measuring Quality Pain and symptom management Patient/family satisfaction Advanced care planning Improved utilization outcomes Hospitalizations Hospital readmission rate Emergency room visits

14 Outcome Data Quality Outcome Data Collected to Lead Improvement in Services Over Time Physician satisfaction surveys Hospital satisfaction surveys Providing quarterly reports on patients enrolled in program

15 Thank you

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