Readmission Webinar: Palliative Care April 2, 2013 12:00 to 1:00 pm CST
Welcome and Overview Welcome, thank you for joining us today! Housekeeping This webinar is being recorded and will be archived. You will receive a PDF of today s presentation, as well as a link to fill-out the evaluation and a summary of Q&A. For questions email us: HEN@aha.org. Agenda Palliative Care Q&A 2
Speakers Janine Douglass, MPH, CIC: HRET Denise Remus, PhD, RN: Cynosure Health Rhode Island Hospital: Jeanne Ehmann, MS, RN, CPHQ, Administrative Director Quality Management RIH Pam Gregoire, MS RN, Quality Outcome Coordinator Christine Kearns, MS, CNRN, FNP/BC, Manager of Patient Safety and Quality, Critical Care 3
Palliative Care Definition Palliative care is specialized medical care for people with serious illness. This type of care is focused on providing patients relief from the symptoms, pain and stress of a serious illness whatever the diagnosis. The goal of palliative care is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses and other specialists who work with a patient s other doctors to provide an extra layer of support. Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment. Center to Advance Palliative Care. 2011 Public Opinion Research on Palliative Care: A report based on research by Public Opinion Strategies. 4
Why Palliative Care? Care plan based on patients goals and personal philosophies Improved patient and family satisfaction Pain and symptom management Psychosocial & spiritual support Advance care planning Lower readmission rates Systematic cost savings from earlier access to ongoing palliative care 5
Pursuing Palliative Care Form multidisciplinary team Integrate palliative care into the ICU and ED Educate all staff, patients and families on benefit & how to access Admission assessment includes identification of unmet palliative care needs Coordinate palliative care across the continuum Performance measurement quality outcomes, satisfaction, costs 6
Potential Barriers Access to multidisciplinary team with training in palliative care Acceptance by care team (physicians, nurses, others) Patient and family awareness / knowledge Program funding 7
PALLIATIVE CARE: IMPORTANCE OF THE CONVERSATION Rhode Island Hospital, Providence, RI
Hospital Story Who We Are Rhode Island Hospital / Hasbro Children s Hospital Providence, RI 1 of 4 hospitals in the Lifespan Healthcare System, principal teaching hospital of the Warren Alpert Medical School of Brown University, University Health System Consortium Member 719 beds and is a not-for-profit acute care teaching hospital Seven ICUs and 3 stepdown units Level I Trauma Center for southeastern New England Beacon Award Winner CTIC, Primary Stroke Center Jeanne Ehmann MS, RN CPHQ; Pamela Gregoire, MS,RN; Christine Kearns, MS, CNRN, FNP/BC 9
Palliative Care Plan Advanced Directive Planning Increase patient and family comfort level with making decisions Goal Provide palliative care education, build confidence in communication skills relating to end of life care decisions Enable physicians to engage patients, families and caregivers and feel more comfortable having the conversation 10
Program Goals Improve palliative care in the ICU which includes easing pain and suffering for patients and families Strengthen staff communication skills for addressing palliative care and end-of-life issues Improve ICU infrastructure to support a strong palliative care program
Intervention Palliative Care Plan Partner with residents, physician assistants, advanced nurse practitioners, nurses, attendings, social work Create openness, mindfulness, listening skills, discuss burden and how family is coping Encourage consults: General criteria for palliative care consult: alive in 1 year, 3 or more admissions in past 6 months, any code situation, 3 or more co- morbidities
RI ICU COLLABORATIVE Statewide ICU Collaborative formed to improve patient outcomes in 2005 Project Managed by Healthcentric Advisors, the RI Quality Improvement Organization Hospital Association of RI Began with Clinical Care bundles: VAP,CL-BSI, CAUTI, Sepsis Communication Bundle Palliative Care 2010 present
ICU Collaborative Palliative Care Bundle ICU Palliative Care Bundle Components 1) Engaged physicians, PA, APNs, and nursing: have the end of life discussion and secure advanced directive, and code status within the first 24 hours engaging patients and family 2) Uniform documentation in the medical record 3) Included in SBAR if a transfer: Emergency room, post op, physicians office 4) Daily reinforcement and weekly feedback for 30 days 5) Recognition of success meeting target * Title changed to Communication bundle to facilitate acceptance 14
RI ICU Communication Bundle Day 1 measures 1. Proxy decision-maker identified AND documented in medical record within 24 hours 2. Presence or absence of advance directive identified AND documented in medical record within 24 hours 3. CPR status addressed AND documented in medical record within 24 hours
RI ICU Communication Bundle Day 1 measures cont d 4. Pain assessment completed AND documented in medical record within 24 hours 5. Dyspnea assessment completed AND documented in medical record within 24 hours 6. ICU informational brochure provided to family AND documented in medical record within 24 hours
RI ICU Communication Bundle Day 3 measures 7. Family meeting scheduled, occurred, and documented within 3 days 8. Patient prognosis discussed at the family meeting and documented 9. Patient goals discussed at the family meeting and documented 10. Need for spiritual care was evaluated, provided and documented within 3 days
ICU Collaborative Communication Bundle Results Since 2005 Advanced Directive compliance rate improved 166.5%! CPR Status compliance rate improved 16.7%! Pain Assessment compliance rate decreased 2%! Dyspnea Assessment compliance rate met & is above target 99.63%
Communication Bundle Results Family Spokesperson compliance rate improved 10%! ICU Brochure compliance rate improved 11% Family Meeting compliance rate improved 155% Spiritual Care rate met & is above target 65.3%
ICU Indicator Results: Compliance with bundle elements INDICATOR 2010 2012 Communication Bundle: Adv.Directive 34.36 96.47 CPR Status 79.81 97.96 Pain Assessment 99.39 99.44 Dyspnea Assessment 99.45 99.63 Spokesperson 89.42 ICU Brochure 79.78 Family Meeting 69.70 Spiritual Care 65.30
Current Initiative Palliative Care training (4hr session)-physicians Introduction Making a relationship with death Contemplation exercises concerning death and impermanence Mindfulness -Breaking bad news Listening exercises -Cultural sensitivity Open Communication and being present
Engaging Community Palliative Consults Focus Cancer, COPD, end stage CHF, ESRD, neurological illnesses Nurse Practitioner aligns care with goals and tracks consults (50 patients/month) Approach Data sent to Home and Hospice of RI Speak Up Joint Commission Brochure Palliative Care Service Consult Tool 22
Engaging Community Community/ State Findings: Opportunities - End of Life Care and Communication Tools are helpful in starting the conversation Flagging patients that have been readmitted
Internal operations Multidisciplinary /Ethics /IT-IS Committees: Revised and made user friendly policy and procedures: advance directives, medical decision making, code status orders Paper to electronic code status (April 2013) Electronic HX of code status Electronic Hx of advance directives, pain care plans, POA, etc.
Internal Operations We strive to interact with other disciplines including nursing, chaplaincy, case management, SW, PT when appropriate in addition to the consulting team.
Lessons Learned Opportunities : Hospital Palliative Care Education Nursing Home Palliative Care Visiting Nurses Palliative Care Aging & Disability Resource Centers Treatment Protocols Code status for all admissions Begin conversations in PCP office, at home 26
Contacts Resources Patricia Colonies and Christine Kearns Nursing Quality & Safety Managers Critical care: ckearns@lifespan.org; pcolonies@lifespan.org Mitchel Levy, MD- Director MICU, Co-Chair RI ICU Collaborative: mitchell_levy@brown.eduri Hospital Palliative Care Nurse Practitioner Rachel Roach, RNP: rroach@lifespan.org Margaret Vigorito, ICU Collaborative Project Manager Healthcentric Advisors: mvigorito@healthcentricadvisors.org RIH Quality Management: Jehmann@lifespan.org, Pgregoire@lifespan.org RIH ICU Collaborative Team RIH Ethics Committee 27
Questions? 28
Additional Palliative Care Resources Center to Advance Palliative Care website is http://www.capc.org/ National Palliative Care Research Center, website is http://www.npcrc.org/ The Joint Commission, Advanced Certification for Palliative Care Programs, information available at http://www.jointcommission.org/certification/palliative_care.aspx Palliative Care and End of Life Care, Consensus Report, The National Quality Forum, http://www.qualityforum.org/publications/2012/04/palliative_care_and_ End-of-Life_Care%E2%80%94A_Consensus_Report.aspx. Accessed March 29, 2013. 2011 Public Opinion Research on Palliative Care: A report based on research by Public Opinion Strategies. Available at: http://www.capc.org/tools-for-palliative-care-programs/marketing/publicopinion-research/2011-public-opinion-research-on-palliative-care.pdf. Accessed March 29, 2013. 29
Palliative Care Resources (cont.) Palliative Care Services: Solutions for Better Patient Care and Today s Health Care Delivery Challenges. Health Research & Educational Trust, Chicago: November 2012. http://www.hpoe.org/palliative-care-services. Accessed March 29, 2013. Beresford, L. Multidisciplinary Palliative-Care Consults Help Reduce Hospital Readmissions, The Hospitalist, February 2013. Silow-Carroll, S & Lashbrook, A (2011). Mercy Medical Center Reducing Readmissions Through Clinical Excellence, Palliative Care, and Collaboration. The Commonwealth Fund, http://www.commonwealthfund.org/publications/case- Studies/2011/Mar/Mercy-Medical-Center.aspx. Accessed March 29, 2013. 30
Upcoming Webinars Date Time Topic Tuesday, April 16, 2013 12 pm 1 pm central Optimizing the Observation Unit Tuesday, May 7, 2013 12 pm 1 pm central How are ACO s Reducing Avoidable Readmissions? Tuesday, May 21, 2013 12 pm 1 pm central Reexamining the Discharge and Transition Process 31
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