12/6/2016

1

PALLIATIVE CARE IN THE

NURSING HOME

Deborah Morris, M.D. , M.H.S.

Assistant Professor of Medicine

The Glennan Center for Geriatrics and Gerontology

Eastern Virginia Medical School

Describe program development and expansion.

Identify benefits of palliative care in the

nursing home.

Create best practices for your nursing center for

advance care planning, palliative care, and

hospice

Objective

• Nearly 70 percent of Americans die in a hospital, nursing home or long-term-care facility.

• 7 out of 10 Americans say they would prefer to die at home.

• Only 25 percent of Americans actually die at home.

Source: Centers for Disease Control (2005)

Source: Time/CNN Poll (2000)

Medical Care in the US

• Few cures

• Live much longer with chronic illness

• Prolonged dying process

Curative Care Palliative

Care

Diagnosis Dying/ Hospice

benefit

Death

• Problems:

• Symptoms and need occur across the period of illness

• Dying Phase is difficult to predict

Cure Disease

Prolong Life

Restore or maintain function

Treat symptoms

GOALS

Palliative Care

Primary Benefits: Care tailored to patient and family goals

“The Right Care at The Right Time”

• Helps doctors, patients and families set realistic goals

• Improves communication between patient/family and health care providers

• Improves pain/symptom management

• Improves patient/family satisfaction

• Improves mortality for cancer patients

• Improves QOL for all patients, and does not shorten survival

Secondary Benefits

• Reduce hospitalization

• Reduce costs

6

Palliative Care

12/6/2016

2

Delivering Palliative Care

Inpatient

Care

Home

Outpatient

Office

SNF • Limited access

• Limited workforce

• Not integrated to

healthcare system

• Limited awareness of

providers and patients

of benefits

8

CARES Program:

• Leverage existing palliative care resources to create a

collaborative program

• Site: 170 bed nursing home in Norfolk, Virginia.

• Collaborators:

EVMS Palliative Care (PC) physician

System Chaplain, Nursing Center Staff

Phase 1: Education

Phase 2: Consultation and Process Revision

Phase 3: Develop best practice tools and

metrics to expand PC to other nursing centers

CARES Program

Baseline assessment of knowledge and

attitudes

Inservices on core palliative care topics

Online curriculum for future staff and ongoing

training

CARES Program Phase 1:

Consult services

Process development and EMR tools

Comfort order set

Goals of Care Family meeting template

PC screening tools

Initial plan 12 months- took 24months

CARES Program Phase 2:

Table 1 : Resident Characteristics N= 170

Age (Years, mean) Range 32-100 75 ( SD 15)

African American (n, %) 77, 45%

Female (n, %) 104, 61%

SNF (n, %) 82, 48%

LTC 88, 52%

Diagnoses

Failure to Thrive/Debility 45, 26%

Cancer 26, 15%

Cardiac 4,2%

Pulmonary 10, 6%

Dementia/ Neuro 66, 39%

Other 18, 11%

Chronic Pain 1, 0.5%

Palliative Performance Scale (PPS)

(mean, SD)

40 (10)

Full Code (%) 79

Table 2: Reason for Referral PAIN NON-PAIN GOALS OF CARE SUPPORT

N 91 112 140 149

Prevalence 54% 66% 82% 88%

12/6/2016

3

CARES Program Phase 2: Outcomes

Hospice 96%

Hospital 4% LTC Deaths

Hospice 25%

SNF without

hospice 53%

Hospital 22%

SNF Deaths

90% Residents with palliative goals were never hospitalized

Leverage partnerships

2014 discussions with private medical group

and hospital to fund PC Nurse Practitioner at

2 “sister” Nursing Centers

System Expansion:

Site 2: PC Nurse Practitioner

Site 2: PC Nurse Practitioner

Leverage partnerships

2nd NP replaces MD at Site 1 (funding

through partner hospital)

MD begins assessment and training at Site 3

(funding through nursing centers)

Discussions with partner hospital

System Expansion:

Staff and leadership turnover extend timeline

Constant education

Identify Site Champions

Establish primary palliative care best

practices

Program Lessons:

12/6/2016

4

Communication

Prognostication

Symptom management

Primary Palliative Care Best Practices

Usually receives MOST

(or all) attention

Communication

Diagnosis Prognosis

Intervention

Not always talked about

Goals

Rarely addressed

20

Communication • Resources

• www.Vitaltalk.org

• www.capc.org

• Theconversationproject.org

• http://www.mypcnow.org/fast-facts

Best Practices

• Discuss goals every person, every time

(NOT just crisis)

• Advance care planning

• Documentation templates

Prognostication • Apps and online

• www.eprognosis.org

• www.capc.org

Best Practices

• Prognostic tools are a guide of

what MAY happen

• If time is short, priorities

change

• Days to weeks, weeks to

months, months to years

• Anticipate

• Expected decline

function, symptoms and

prepare individual/family

Symptom Management

• Apps and online

• http://www.mypcnow.org/

fast-facts

• www.capc.org

Best Practices

• Standard assessment and

documentation of symptoms

and palliative care needs

• Consistent evidenced based

treatment of symptoms

• Ordersets

12/6/2016

5

• Screen, Assess, Treat

and Document

Physical, Emotional,

and Spiritual Needs

Palliative Care IDT Rounding Tool

Name

Age

Room

Admission

Attending

Medical Summary:

Life limiting illness: Y/N _____________________

Decline: Y/N as evidenced by_________________

Prognosis (Eprognosis): _____________________

Psychosocial:

AD/Living Will: On file Y /N

Legal Decision-maker: at this time

______________

When patient loses capacity:

_________________

Determined by: MPOA,

guardianship, surrogate laws

POST: On file Y/N

Depression Screen: Y/N

Veteran:

Physical Symptoms:

Pain: Y/N

Delirium: Y/N

Anorexia: Y/N assistance, supplements,

Dyspnea: Y/N

Nausea: Y/N

Constipation: Y/N

MAR reviewed Y/N Changes rec Y/N (see below)

Available care plans reviewed.

Prior resident/family meetings

documented Y/N

Resident Goals: curative, palliative,

combination, undetermined

Family Goals: curative, palliative,

combination, undetermined

Focus: life prolonging, function,

comfort

Spiritual:

F Faith or Beliefs: What things do give meaning to

resident’s life?

I Importance and Influence: What role do your

beliefs play in regaining your health?

C Community: Are you part of a spiritual or

religious community?

A Address: How would resident like staff provider

to address these issues?

Summary: Resident is a

______________________________________________________________

Potential needs detailed above:

o Physical

o Spiritual

o Psychosocial

Recommendations:

o SW meet with resident to complete ACP/POST

o Recommendations for medication, care plan changes detail below and will be

provided to primary attending.

_______________________________________________________________________

__

_______________________________________________________________________

__

_______________________________________________________________________

__

_______________________________________________________________________

__

o Chaplaincy CARES referral for spiritual needs.

o CARES Consult for complex symptom needs

o CARES Consult for family meeting, to coincide with care plan when possible

o Referral to hospice

Standardize Primary Palliative Care Best Practices Current Efforts:

Time Line Practices Relevant Tools

Admission Advance care planning (ACP)

Identification of Legal decision-makers

Assessment of current medical status, prognosis,

goals, and needs (physical, spiritual,

psychosocial)

Code status

Life review and planning

- Eprognosis Mortality

Calculators

- PC Screening Tool

- IDT Rounding Tool

- Goals of care/Family

Meeting Template

- POST

Quarterly Assessment of current medical status, prognosis,

goals Assessment of needs (physical, spiritual,

psychosocial) and discuss with resident/family

Review advance care plan and legal decision-

maker

- Family Meeting Template

- IDT Rounding Tool

- Eprognosis Mortality

Calculators

- FICA Spiritual Assessment

12 month

prognosis

As above and

ACP: POST

Hospice education

- As above

- POST

6 month

prognosis

As above and

ACP: POST

Hospice education and referral

- As above

- POST

- Comfort care order set

Check all that apply. If resident meets one or more criteria, consider an order for palliative care consultation.

Basic Disease Process o Cancer (metastatic or recurrent)

o Stroke (with decreased function or

dysphagia)

o Advanced cardiac disease (CHF EF<25%,

severe CAD)

o End stage renal disease

o Advanced dementia

o Advanced COPD (dyspnea, oxygen

dependence)

o Other life limiting illness

Co-existing conditions or

Critical Incidents

o Considering (or have) PEG/feeding tube

o Long term ventilator support

o Stage 3 or 4 pressure ulcers

o Recent ICU stay

o Multiple ER visits (2 or more in past 3

months)

o Multiple hospitalizations (2 or more in past

3 months

o Palliative care consult in hospital

Symptoms

(Uncontrolled or Chronic )

o Pain

o Nausea

o Delirium

o Decrease function in last 1-3 months

o Fatigue

o Other: ____________

Decision-making/

Communication

o No Advance directive

o Clinical status calls for discussion/or

there is conflict about code status

o Resident or surrogate distressed about

decision-making

Psychosocial o Limited social support

o Resident/family lack of coping skills

related to illness, prognosis, etc

o Spiritual needs: Resident/family exhibit

fear, guilt, or grief

Domain of Care Possible Needs (check all that apply) Interventions

(check those that are implemented)

Physical Comfort/Function o Resident needs pain and symptom

management

o Patient needs help to reach maximum

desires/possible functional level

o Palliative care consult (pain and symptom

management)

o Physical therapy or occupational therapy

o Addressed by staff _______________

Communication/ Decision-

making

o Resident/family lack understanding of

diagnosis, prognosis, or treatment plan

o Resident/family need/desire help with

decision-making (including advance

directive)

o Conflict about treatment decisions

o Provide education

o SW

o Palliative care consult

o Addressed by staff

_____________________

Psychosocial/

Emotional Concerns

o Resident/family exhibit anxiety, lack of

coping skills

o Resident/family fear, anger, guilt, grief

o SW

o Palliative care consult

o Spiritual care referral/ connect to

community based clergy

Palliative Care Screening Tool Step 1: Screen for palliative care needs - Record information READILY available in the clinical documentation or resident/family encounters. Use this tool within 3 days of admission. Step 2: Assess and meet palliative care needs

System Expansion Outcomes

Aug-Dec 2015

% total deaths with

hospice

%LTC deaths with

hospice

% resident death

hospital %death SNF

Site 1 38% 66% 7% 32%

Site 2a 53% 76% 3% 13%

Site 2b 40% 64% 6% 28%

Site 3 13% 20% 28% 32%

H 6% 8% 35% 48%

P 32% 48% 4% 32%

2016 TD

% total deaths with

hospice

%LTC deaths with

hospice %death hospital %death SNF

Site 1 37% 50% 2% 21%

Site 2a 47% 64% 3% 18%

Site 2b 74% 89% 3% 15%

Site 3 52% 75% 3% 24%

H 43% 48% 14% 11%

P 26% 36% 3% 19%

C 46% 55% 0% 17%

PALLIATIVE CARE

30

All patients & families should receive the RIGHT

CARE, at the RIGHT TIME and in the RIGHT

SETTING.

12/6/2016

6

31

REFLECT: WHAT CAN YOU DO NOW?

CONTACT INFORMATION:

Deborah Morris MD, MHS

Palliative Medicine

Eastern Virginia Medical School

morris01@evms.edu