Hospice Case Management

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1 Defining Quality Hospice Case Management Cindy Henderson, BSN, RN, CHPN Director of Operations Acclaim Hospice and Palliative Care Kindred Healthcare, Inc. Objectives At the end of the session, participants will be able to: Understand the regulations regarding oversight of the hospice plan of care by the RN Case Manager Understand the standards of practice for the hospice RN Case Manager Explain key components of the hospice RN Case Manager role Identify the educational components for training the hospice RN Case Manager 1

2 Regulations (a)(1) The hospice must designate a registered nurse that is a member of the interdisciplinary group to provide coordination of care and to ensure continuous assessment of each patient s and dfamily s needs and dimplementation i of the interdisciplinary plan of care. 2

3 Regulations Hospices are free to refer to the coordinator in a manner that t meets their needs, as long as there is an individual identified as being responsible for coordinating and implementing each patient s plan of care RN Case Manager works under the supervision of the clinical manager Regulations Case Manager needs to have solid knowledge of the biological, psychological and spiritual issues of terminally ill patients and their families. 3

4 Regulations Case Manager acts as an advocate, negotiator, and leader when dealing with the varied members of the IDG, the patient and the patient s family. Regulations The registered nurse has the necessary medical and interpersonal background to meet the demands of the coordinator position in a way that no other discipline does. The nurse is designated as the coordinator of the plan of care, or Case Manager 4

5 Regulations Shift of focus from a reactive to a proactive patient/family centered approach Scope and Standards of Practice Developed by the Hospice and Palliative Nurses Association Authoritative statements The standards identify the responsibilities for which the hospice and palliative a nurses are accountable. 5

6 Standards of Hospice and Palliative Nursing Practice The standards of practice are divided into two sections: Standards of Practice Standards of Professional Performance Standards of Hospice and Palliative Nursing Practice The GOAL of the hospice nurse is to promote and improve the quality of life: Aggressive efforts to relieve pain Relief of suffering 6

7 Standards of Hospice and Palliative Nursing Practice Through appropriate care, individualized for one s specific needs, the patient and family are able to attain a degree of mental, emotional, and spiritual preparation for a death that is satisfactory to them. Help people live until they die. Standards of Hospice and Palliative Nursing Practice In all aspects of care, the hospice and palliative nurse demonstrates: critical thinking analysis clinical judgment 7

8 Standards of Hospice and Palliative Nursing Practice Optimize the comfort and dignity of patients Provide care that is consistent with patient and family needs and goals, with patient needs and goals as priority. Ensure that patient care is furnished in a safe and effective manner Standards of Practice Follow the nursing process: Assessment Diagnosis Outcome identification Planning Implementation Evaluation 8

9 Standard of Practice Assessment: Collects comprehensive data pertinent t to the patient s t health or the situation Collect data: on-going process Collect data from the family or other healthcare providers Prioritize care based on the immediate needs and culture of your patients/families. Assess data using the appropriate tools for hospice care PPS BMI FAST scale Psycho-social items Spiritual needs Identifies patterns and variances Document assessment Communicate assessment with IDT members and/or consultants 9

10 Standard of Practice Diagnosis: Analyze the assessment data to determine the nursing diagnoses or issues Problems to be addressed: with actual or potential responses Validate the issues with the patient/family or healthcare provider Consider the age and condition of pt when formulating the nursing diagnoses Document and communicate Standard of Practice Outcomes Identification: Identifies expected outcomes for the plan of care. Individualized for the patient Involve pt/family, other healthcare providers, and IDT members to formulate expected outcomes to improve quality of life Benefit/Burden Age and culturally appropriate 10

11 Patient/family goals for care Time frame to meet the goals Assure for continuity of care goals across all care settings Modify goals according to patient condition/circumstances Document Communicate Standard of Practice Planning: Develop a plan of care that prescribes strategies and alternatives to attain expected outcomes Individualized care plan based on choice, and appropriateness for the patient s age, culture Strategies may include promotion and restoration of health and prevention of illness, injury, disease Continuity of care across all settings. 11

12 Standard of Practice Best practice Economic impact Compliance with rules/regs, standards Communicates with the IDT Standard of Practice Implementation: Implement the identified plan of care Appropriate interventions/treatments specific to the diagnosis Care Coordination Provides education Safety Timely implementation 12

13 Standard of Practice Facilitates change in plan of care as needed after consultation with the IDT, family or other health care providers Remains compliant with rules/regs Documents Standard of Practice Evaluation: Evaluates progress towards reaching the expected or desired outcomes Makes changes to the plan of care as indicated Collaborates with patient/family, other healthcare providers, IDT Documents 13

14 Standards of Professional Performance Quality of practice: Nurse systematically enhances the quality and effectiveness of nursing practice. Responsible Accountable Ethical Utilizes new knowledge for decision making/interventions when desired outcomes are not achieved Standards of Professional Performance Education: attains knowledge and competency that reflects current hospice and palliative nursing practice Professional Practice Evaluation: Evaluates one s own nursing practice in relation to professional standards and guidelines, rules/regs 14

15 Standards of Professional Performance Collegiality: Interacts with and contributes to the professional development of peers and colleagues Shares knowledge and skills Interacts with peers to enhance one s own professional practice and performance Maintains caring and compassionate peer relationships Contributes to a supportive and healthy work environment Standards of Professional Performance Collaboration: Collaborates with the patient, family, IDT, and others Communicates the nurse s role in the provision of care Partners with others to effect change Collaborates and documents 15

16 Standards of Professional Performance Ethics: integrates ethical provisions in all areas of practice Research: integrates research findings into practice Resource Utilization: considers factors related to safety, effectiveness, cost, and impact on practice in the planning and delivery of nursing service Standards of Professional Performance Leadership: provides leadership in the professional practice setting and the profession. 16

17 Key Components of the RN Case Manager Role Case Manager versus Visit Nurse: What differentiates the two roles? Case Manager or Visit Nurse? Visit nurse: Assessments Treatments Interventions Collaboration with the Case Manager Likely to see the patient at one point in time 17

18 Key Components of the RN Case Manager Role Case Manager: Must coordinate the work of the interdisciplinary team. Coordinates each patient s plan of care as effectively and efficiently as possible. Implements care as effectively and efficiently as possible Evaluates the care provided Monitors outcomes of care Role of the Case Manager Clinical oversight of plan of care, including disciplines involved in the patient s care Are the physical, psychosocial, spiritual needs being met? Clear understanding of the pt/family goals for care and dthe outcomes of fthe care 18

19 Role of the Case Manager Social Worker Reviews documentation Collaboration to coordinate interventions to achieve goals All issues identified and communicated across the IDT. Role of the Case Manager Spiritual Care/Counselor Reviews documentation and/or collaboration to assure goals don t conflict Awareness of religious rituals and expectations at time of death If no SCC is visiting, i i are the spiritual i needs still being assessed? 19

20 Role of the Case Manager STNA STNA assignment developed with pt, family, and current caregivers Supervision every 14 days STNA present STNA not present Volunteer Purpose/goals for care Other disciplines, i.e. therapies Role of the Case Manager In collaboration with the IDG team, the case manager identifies the need to adjust the scope and frequency of the discipline s visits to achieve goals ************ Adjusts orders as indicated 20

21 Role of the Case Manager Clear understanding of the following: Terminal diagnosis for each pt. Aware of pt s. health history LCD guidelines for the different diagnoses Assessment identifies the key qualifiers for the diagnosis and the documentation supports the diagnosis Determines if the diagnosis is still the appropriate terminal diagnosis Role of the Case Manager The Case Manager understands: Benefit periods 90 days 60 days Face to face physician encounter requirements Expectations for insurance reimbursement Dates for recertification Appropriate information presented at IDG meetings for medical director to review 21

22 Role of the Case Manager Nurses relay information to the Medical Director Conduit C d between the attending physician i and the medical director Understands the responsibility of the Medical Director s role of oversight for the medical aspect of the plan of care Case C manager will relay to the Medical Director the complete and concise picture of the pt status as it relates to the certification or recertification of a pt. Role of the Case Manager Management of drugs, medical supplies and DME Safety Education Appropriate use Cost: Aware of costs for care Supplies Meds Interventions Diagnostics etc. 22

23 Role of the Case Manager Assessment of appropriate level of care and changes to the plan of care Routine Continuous Care Respite GIP Role of the Case Manager Ensures all providers work as a team SNFs ALFs Caregivers Working towards the same goals Assures the goals are pt/family driven Documentation shows evidence of collaboration 23

24 Role of the Case Manager Infection control Prevention Control Education Role of the Case Manager Strong clinical and assessment skills Eyes and ears for the physician Understanding of the disease trajectory of pt Assessment of H/P, secondary dx, and comorbids Effectiveness of current medication regime Communication with physicians Communication with pts/families/caregivers 24

25 Role of the Case Manager Critical thinking skills What is needed for palliation of symptoms Anticipate needs Monitor care from previous interventions Who should be involved Are symptoms physical, emotional, or spiritual in nature? Solid nursing judgment Role of the Case Manager Organizational and time management skills Expectations increased Decreased reimbursement Point of care documentation 25

26 Role of the Case Manager Flexibility Supportive to the team People Skills Collaboration and Conflict resolution Families Facilities Physicians Excellent Listening skills Role of the Case Manager Ability to work independently Collaboratively Integrity/Professionalism Need to be able to trust them in the field to be doing what they say they are doing Comfortable with difficult conversations Food and fluid decisions, code status, death and dying 26

27 Educational Needs Hospice as a philosophy of care Must understand and educate on comfort care goals versus curative goals for care Assist pts/families in making informed decisions Define Hospice and/or Palliative Care Change in mindset from acute care or long term care Eligibility Educational Needs Terminal diagnoses LCD guidelines Evaluating for care Reimbursement Regulations CoPs Conditions of Participation 27

28 Educational Needs Medicare Hospice Benefit What is included in the benefit Compliance Face to Face requirements Levels of Care Reimbursement Insurance plans Medicaid Educational Needs Pain and symptom management Included in the regulations as a patient right Must possess solid working knowledge of interventions People defer to hospice recommendations Equianalgesic dosing Optimal choices for medications 28

29 Educational Needs The Hospice Team Understanding of the role for each team member Expectations for visits from each team member Scope S and frequency of visits i Educational Needs Policy/Procedures Solid working knowledge Compliant 29

30 Educational Needs Supervisory Role STNA Plan of care Supervision Competency Educational Needs Hospice as a business Hospice as a business Solid working knowledge and understanding of the business aspects of care/costs Supplies DME Medications Diagnostics and testing, treatments Mileage OT 30

31 Special Considerations Identifying i end of life tasks Focus on the whole person Symptoms are managed so the emotional and spiritual work of dying can be completed What t EOL tasks need to be accomplished for a peaceful death to occur? Special Considerations Boundaries Healthy boundaries maintained Appropriate hand-offs to the interdisciplinary team Enable and empower the family, care-giver or facility to care for the patient at end of life and in the dying process 31

32 Special Considerations Survey Climate Need to be survey ready every day Increased scrutiny ADRs, RACs, CERTs, ZPICs, etc Competency is reflected in the medical record decreasing the potential for denials Differentiators for your hospice! Competent Case Managers: Improved outcomes for pt/family Goals achieved Symptoms managed Quality of life improved Death with dignityi Positive effect for bereavement of family members Decreased cost to the healthcare industry 32

33 Differentiators for your hospice! Positive impact on the hospice industry Skilled and competent case managers will find increased respect in the health care community for their expertise in end of life care Positive impact on the hospice organization World Class or Stellar hospice care Differentiators for your hospice! Greater job satisfaction: Case mangers see clearly the impact they have on the patient and family s quality of life Positive effect on recruitment Staff retention Greater continuity of care for pts/families Financially beneficial 33

34 To laugh often and much; to win the respect of intelligent people and the affection of children; to earn the appreciation of honest critics and to endure the betrayal of false friends. To appreciate beauty; to find the best in others; to leave the world a bit better whether by a healthy child, a garden patch, or a redeemed social condition; to know that even one life has breathed easier because you have lived. This is to have succeeded. Ralph Waldo Emerson 34

35 Questions! THANK YOU! 35

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