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NAHC Annual MeetingNovember 3, 2013
The Palliative Home Care Program: Our Agency’s Experience
Washington, D.C.
NAHC Annual MeetingNAHC Annual MeetingNovember 3, 2013 Washington, D.C. Presented by:
Karen Marshall Thompson, RN, MS, CNSJenni Smathers, RN, BSN
SOMC Home Health Services Portsmouth, OH
• First Hospital‐Based Agency in OH
SOMC Home Health ServicesSOMC Home Health Services
• Medicare‐certified in 1966
• Serve three counties
• Currently opening a new office in KY
• Expanding into two additional counties in OH
• Home Care Elite 2006, 2007, 2008, 2011, 2012
JCAHO A di d• JCAHO – Accredited
• Offer traditional Medicare – certified home health services
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• Definition:
Why Palliative Care?Why Palliative Care?
The care of patients with progressive disease
The Goal: Relief of suffering
P i d t t‐ Pain and symptom management
‐ Advance care planning
‐ Improved care coordination
• Most people die now from advanced
Why Palliative Care?Why Palliative Care?
p pchronic illness
• 70% of Americans prefer to die at home
BUT
Th f f l till di i h it l• Three of four people still die in a hospital
or skilled nursing facility
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• Medicare expenditures in the last two
Why Palliative Why Palliative Care?Care?
pyears of life
Average cost/beneficiary $46,412 (2001‐2005)₁
• Avoidable costly and debilitating hospital• Avoidable, costly and debilitating hospital stays
• Bullet ₁ Center for Home Care Policy and Research 2009
• Dr. JoAnne Lynn₂
Why Palliative Care?Why Palliative Care?
J y ₂
₂Lynn, JoAnne (2001) JAMA 285(7); 925‐932
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• Dr. JoAnne Lynn (2001)
Why Palliative Care?Why Palliative Care?
• Dr. JoAnn Lynn (2001)
Why Palliative Care?Why Palliative Care?
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• Recognized need for symptom control
Why Palliative Care?Why Palliative Care?
g y p
and coordination of care for patients
with advanced chronic disease
• Designed for patients who are not yet d f H iready for Hospice
• Provides specialized Home Health Services
• Patients qualify for skilled intermittent
Program Structure Program Structure
q yhome health services
‐Medicare COP’s
‐ OASIS, HH‐CAHPS
H b d‐ Homebound
‐ Skilled Care Need
‐ Under the care of a physician
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“A Home Health Program with a Hospice
Components of Components of the the ProgramProgram
g p
Philosophy”
‐ Patients are educated regarding treatment options
T iti f t t t ti‐ Transition of treatment options
‐Ongoing Advance Care Planning/End of Life Discussions
• Patients may pursue “curative” treatment
Components of the ProgramComponents of the Program
y pe.g. chemotherapy, radiation, aggressive antibiotic therapy and diagnostics
• May have a prognosis of greater than 6 monthsmonths
• May choose palliative care but not Hospice care
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• RN Case Manager
Components of the ProgramComponents of the Program
g
Caseload approx. 20 patients
Productivity Standard 3 visits/day
**Important concept ‐ Continuity of icaregiver
• Pain & symptom management protocol
• Chaplain, bereavement and volunteer
Components of the ProgramComponents of the Program
p ,disciplines are unique to the Hospice
benefit and are not offered services
• Access to Hospice expertise for pain and symptom managementsymptom management
• PC/Hospice staff comprise the IDT
which meets monthly
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All cancer dx’s Neuromuscular
Common DiagnosesCommon Diagnoses
End Stage Renal Disease
End Stage Heart Disease
Disease
End Stage Pulmonary Disease
HIVDisease
Advanced liver disease
HIV
• 24/7 Availability through Home Care
Components of the ProgramComponents of the Program
/ y g
On‐Call mechanism
• Education for Skilled Intermittent Staff:
‐Pain & symptom management
‐ Advance directives
‐ Difficult discussions
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Palliative Care Practitioner ProgramPalliative Care Practitioner Program
• Our newest Palliative Care service
• Palliative care‐certified nurse practitioners
• Inpatient consultation – SOMC Main Campus
• Outpatient Palliative Care House Calls‐Provided wherever the patient calls home:
‐ Residence
‐ Skilled Nursing Facility
‐ Assisted Living
• Physicians
Educating Other Members Educating Other Members of the Health Care Teamof the Health Care Team
y
• Discharge Planners
• Nurses
• Cancer Center
Palliative Care is NOT Hospice and it is
NOT “Hospice Lite”
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• FY ‘11 Top DX’s:
OutcomesOutcomes
Patients Served: 47
Visits: 1190
Visits/Patient 25.3
p
CHF
Lung CA
Transition to Hospice:
79%
• FY 2012 Top DX’s:
Outcomes Outcomes
Patients Served 196
ALOS 106 days
14 visits/patient
p
CHF
Lung Ca
Transition to Hospice:
52%
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• FY 2013 Top DX’s
OutcomesOutcomes
Patients Served 112
ALOS 192 days
Visits/patient 20
p
SubendocardialInfarct (410.72)
Lung CA
CHFTransition to Hospice:
43%
CHF
• Communication
ChallengesChallenges
• Turnover – New staff in HH, Hospice, Hospital Discharge Planners, Cancer Center
• Ongoing education• Ongoing education
• Home Care nurses’ discomfort On‐Call
• Transitions
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Case Management/Team Structure Case Management/Team Structure Palliative CarePalliative Care
Home Care Case Hospice Philosophy &
PatientPatient‐‐ Centered ApproachCentered ApproachHome Care Case Management
• Palliative Care CM• Smaller case load• Extended service area• Attend office visits• Facilitate family meeting
visits – hospital & home
Hospice Philosophy & Support
• Knowledge of Hospice care• Use Pain/Symptom
Management protocol• Initial intake per Hospice • Hospice Social Worker
covers patients
Demographics:•78 y/o Congestive heart failure Diabetes
The Case for BobThe Case for Bob
78 y/o Congestive heart failure, Diabetes, Hypertension, Chronic Renal Failure
•Spouse Hospice patient (former PC patient)
•EF decreased from 30% to 15% since admission
•Only 1 hospitalization •Utilized Telehealth daily
•Multiple exacerbations, medication changes and education needs
•Able to attend multiple Dr. appointments
•Obtained standing orders for lab/increased diuretics
•Length of stay = 160 days
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The Case for BobThe Case for Bob
Declined Declined DNRCCDNRCCUntil after Dyspnea
Episode ED Visit w/o Admission
EF EF Declined Declined to 15%to 15%
Recognized Recognized Decline & Decline & Agreed to Agreed to
Hospice CareHospice Care
Passed Passed Peacefully Peacefully At HomeAt Home5 Days after Hospice Admissionw/o Admission
CHF ManagementCHF Management• Due to non‐reimbursement if readmission in 30 days, PC provides CHF patients with:PC provides CHF patients with:– Aggressive education and frequent visits– Better continuity due to smaller case loads– Frequent communication with their physician– Telehealth monitoring (includes weight, BP, et pulse oximetry)for chronic intervention and management of diseasedisease
– Encouragement of SNV before ED if non‐emergent– 24 hour on‐call service per Home Care staff
• Physicians more willing to give standing lab/diuretic orders based on assessment.
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The Case for AngieThe Case for AngieDemographics:• 34 y/o married mother of 3 diagnosed• 34 y/o married mother of 3, diagnosed
with cervical cancer in 2009 • Metastasis to lymphatic system, bilateral
pleura, et pericardium• Multiple chemotherapy attempts at The
James Cancer Center OSU, Cancer Treatment Centers of America in Chicago, and lastly with local oncologistR f l d f i / t• Referral made for pain/symptom management and disease process teaching
• Utilized IV pain control per CADD pump• Length of stay = 56 days
The Case for AngieThe Case for Angie
Palliative Palliative Performance Performance
Scale (PPS) 60%Scale (PPS) 60%11
Upon Admission
MSW Involved for MSW Involved for Advanced Advanced DirectivesDirectives
Remained Full Code
Significant Significant Decline in Decline in ActivityActivity
Increased Dyspnea & Increased Dyspnea & PainPain
1Anderson F, Downing GM, Hill J. Palliative Performance Scale (PPS): A New Tool. Journal of Palliative Care. 1996; 12(1); 5‐11.
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The Case for AngieThe Case for Angie
Oral Pan Meds Oral Pan Meds IneffectiveIneffective
Oncologist Agreed to Dilaudid Pain Control
Initiated Oxygen Initiated Oxygen ContinuouslyContinuously
3L per NC with Albuterol Nebulizer Q2
Palliative Palliative Performance Performance Scale 40%Scale 40%
Within 30 Days of Within 30 Days of EpisodeEpisode
The Case for AngieThe Case for Angie
Received Two Received Two Treatments Treatments
ChemotherapyChemotherapy
Thoracentesis Thoracentesis Performed for Performed for
Pleural Pleural EffusionsEffusions
Minimal Effectiveness
Increased Increased AtivanAtivan
For Increased Dyspnea
Pain Pain Control Control IncreasedIncreasedDilaudid to Dilaudid to 6mg/hr6mg/hr
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The Case for AngieThe Case for Angie
Oxygen Oxygen Saturation Saturation
Decreased to Decreased to 84%84%
Continued Continued Education on Education on
Disease Disease ProgressionProgressionDeclined Hospice
Care
Transferred Transferred to Hospitalto Hospital2 Days After last
HC Visit
Continued Continued Daily VisitsDaily VisitsLast 16 days of Last 16 days of PC in HospitalPC in Hospital
Care
The Case for AngieThe Case for Angie
Palliative Palliative Performance Performance Scale 20% Scale 20%
Bipap Initiated During Bipap Initiated During
Hospital StayHospital Stay
Physician Physician Called PC to Called PC to Explain Explain DNRCC & DNRCC & HospiceHospice
Transported Transported to Inpatient to Inpatient Hospice Hospice CenterCenter
With PC Case
Hospice Hospice Admitted at Admitted at
CenterCenterRemained until Death 24 hours
LaterppManager
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Summary• Our Palliative Care program has been the vision of both Homecare & Hospice leaders and Administration.
• Ultimately, we have the ability to provide ExcellentPatient‐Centered care with a genuine team approach.• Palliative Care offers a
Home Care program with a Hospice philosophy
Any Questions?Any Questions?
Safety ♦ Quality ♦ Service ♦ Relationships ♦ Performance