Hospice Certification, Care Planning and Documentation:

Transcription

1 Hospice Certification, Care Planning and Documentation: Created by: Created by: Brenda Lovelady, Liberty Hospital Hospice Presented by: Robin Carnett, Heartland Hospice

2 Hospice Certification Written certification statement is required I certify that is terminally ill with a life expectance of 6 months or less if the terminal illness runs its normal course.

3 Local Coverage Determination for Determining Terminal Status LCD for Hospice Determining Terminal Status by Medicare- Handout Only a guideline Written for specific diagnoses Must consider co-morbidities

4 Karanofsky Performance Status Palliative Performance Scale Scales to assist in documenting the status of a patient Can be used to study functional level of patients at time of admission, prior to death and prediction ability.

5 Coma/ Stroke Karnofsky Performance Status (KPS) or palliative Performance Scale (PPS) of 40% or less Wt. Loss > 10% in last 6 month Serum albumin <2.5% gm/dl Dysphagia severe enough to prevent adequate nutrition Level of coma

6 Coma/Stroke Supports terminal prognosis Aspiration pneumonia URI Sepsis Decubitus ulcers Fever, recurrent after antibiotics.

7 Alzheimer s-type Dementia Unable to ambulate Unable to dress without assistance Unable to bath without assistance Incontinence B & B No meaningful verbal communication Recent (past 12 months) infections Stage 7 or beyond FAST-

8 End Stage Renal Not seeking dialysis or renal transplant Creatinine Clearance < 10ml/min Serum creatinine >8mg/dl Co-morbidities Intractable fluid overload

9 Heart Disease Failing optimal treatment Symptoms of heart failure at rest Supportive factors Treatment resistant SVT or VT Hx cardiac arrest Unexplained syncope Ejection Fraction <20%

10 ALS Impaired breathing Dyspnea at rest Rapid progression Nutritional impairment Infections

11 Pulmonary Disease Disabiling dyspnea at rest Right heart failure secondary to pulmonary disease Resting tachycardia > 100/min Hypoxemia at rest on room air O2 sat < or =88%

12 Liver Disease INR >1.5 Serum albumin < 2.5 gm/dl Ascities Bacterial peritonitis Progressive malnutrition Muscle wasting

13 Decline in Health Recurrent infections Wt. Loss-(wt., arm circumference, abdominal girth) Dysphagia Dyspnea N/V Weakness PPS < 70%

14 Cancer Distant metastases Progression of disease Decline therapy PPS < or = 70% Assistance with 2 or more ADLs Co-morbidities

15 Process to Determine Eligibility Use all information Input all team members Assessment Agency guidelines Decision

16 Developing the Plan of Care Begins with the referral Providing transitional information to patient and family (Travis, 2001) Interdisciplinary assessments Team sharing and collaboration

17 Overview of Care Plan Model Initial POC Identification of the problem Problem List- Further development of each problem tool-example Cognitive

18 Initial Plan of Care Patient s name and numbers Admit date Diagnosis (s) Physician s name Pharmacy Medications Allergies Initial Problems

19 Initial Plan of Care Specific Treatment Orders Supplies/Equipment/Diet Frequency of Visits DNR wishes Attending sign death certificate Patient/family administer meds POC reviewed by IDG every 2 weeks Signature and verbal approval of nurse, social worker (counseling), Chaplain, attending and medical director

20 Plan of Care Process With IPOC identify the major problems These problems are then further developed on the POC with interventions and goals Remember this is an ongoing process POC should be added to as time goes on!

21 Problem Areas What areas are problematic to document for you?

22 Physician Orders and Plan of Care Included as part of Plan of Care If has medication orders, filed with Medication Plan of Care Order for equipment, filed with Equipment Plan of Care IV Therapy Order Sheet

23 Flow of Documentation Admission assessments Problems identified IDG conferences/summaries Physician orders Patient & family goals Staff visit notes

24 Making it Work Updating the Plan of Care Team takes ownership of POC Any team member can update any identified problem Any team member can open a newly identified problem

25 Documentation Medical Record is a legal document. Writing must be legible/readable Statements must be factual and specific Patient and family quotes may be used Identify time/date of entry with signature and title All telephone contact must be documented. All conversations with physicians and other team members must be documented.

26 Documentation: Support Prognosis Summary from the physician or nurse that identifies clinical symptoms, tests, treatments to show status of condition Discharge Summary or H/P from hospital Changes in conditions Date of diagnosis and course of illness Patient s desires for palliative, non-curative treatment

27 Supportive Documentation: Breast cancer pt. w/ new seizure onset. Brain scan indicating brain metastases. Prostate cancer pt. w/ recent fall resulting in pathological fracture related to bone metastases. Pt. w/ dementia for 11 years. Now in facility for 2 years and has lost 10% of her body wt. Wt. 89 lbs and appetite 25%.

28 Supportive Documentation Parkinson s patient recently returned to care facility following hospitalization for aspiration pneumonia with continuous swallowing difficulties. During a recent care conference, noted s/o decline in long-term pt. with multiple dx. Skin breakdown,recurrent UTIs, low-grade fever and weakness. Albumin level 2.1.

29 Documentation: Support Hospice Change in wt. Change in lab values Change in pain Change in responsiveness Skin breakdown Dependence on ADLs Anthropomorphic measures Upper arm or abd. girth

30 Documentation: Support Hospice Change in respirations Oxygen use Change in B/P Change in strength/weakness Change in orientation Change in intake/output

31 Documentation: Level of Care Routine Home Care Patient in home setting, routine treatment being provided Paint a picture Clinical findings Wt. Loss/gain, VS, wounds, eating Interventions Plan of Care

32 Documentation: Level of Care Continuous Home Care Provided in period of crisis to maintain pt at home. Must include 8 hrs care in 24 hours to achieve palliation or management of acute medical symptoms. Primary services (at least half) must be provided by RN/LPN, may be supplemented with aide/homemaker.

33 Documentation: Level of Care Continuous Home Care Pt. must require skilled services Normal dying process, usually does not qualify for skilled services

34 Documentation: Level of Care Continuous Home Care Should document Dates/times/reason for change in level of care (Pt in severe pain, caregiver unable to control. Cont. care to begin 7/7/09 1 pm.) Interventions Response of pt/family Any adjustment medications/treatments Goals Teaching

35 Documentation: Level of Care Inpatient Respite Care To relieve caregivers, does not require a change in pt s condition Caregiver needs rest so can resume duties as caregiver Caregiver is sick Caregiver leaving town overnight.

36 Documentation: Level of Care Inpatient Respite Care Documentation Tips Date respite started, reason, order Date respite ended, order for change in level of care.

37 Documentation: Level of Care General Inpatient Care Short-term hospitalization for symptom control Requires 24 hour care by RN Examples: Pain management requiring complicated technical delivery of medication Freq. Evaluation by nurse/physician Sudden deterioration Uncontrolled nausea/vomiting Complex wound requiring complex dressing changes

38 Documentation: Level of Care General Inpatient Care Documentation Tips Order change in level of care Date/Time of change Reason for care Assessment Documentation of response

39 Tips to Make the Care Planning Process Work Not merely time-consuming, academic exercise But both documentation tool and implementation plan for individualized hospice care Requires sharing and collaboration Joint effort of members of team to develop care plan model/tool which reflects best practices of agency

40 References Lovelady, B., & Sword, T. (2004). Hospice care planning: An interdisciplinary roadmap. Journal of Hospice and Palliative Nursing, 6(4), Missouri Hospice Licensure Regulations. Medicare Hospice Regulations. Travis, S. (2001). Palliative care: A way of thinking, a prescription for doing. Geriatric Nurse,22,