Palliative Care at SNF - PCQN · 2019. 12. 19. · Medicare SNF benefit in last 6 months of life •Entitled to 100 days of SNF care –After 3+ day hospitalization –Skilled need

Palliative Care at SNF: Should it be part of your program?

Jeffrey N. Stoneberg, D.O.

Medical Director

Alta Bates Summit Medical Center

An inquiry/discussion…

Outpatient Pall Care

• PCQN currently collecting data on outpatient palliative care…

• Does anyone perform palliative care at SNFs? – How often?

– How many SNFs does your program visit?

– Who provides the resources?

– Collaborative between SNF/Hospital?

Why are SNFs important?

• They care for our sickest patients

– Care too complex to provide at home

– Patients with multiple medical conditions

– Often blurred goals of care • Insufficient advance care planning

– Conflicting expectations • Patient

• Family

• Medical team

Why are SNFs important?

• Initial pall care intervention in hospital

– Unable to complete due to pt discharge

– Resume conversations upon readmit instead

of outside of hospital

• Could have avoided the readmit

• Poor physician coverage in SNFs

• Many unmet palliative care issues

Medicare SNF benefit in last 6 months of life

• Entitled to 100 days of SNF care – After 3+ day hospitalization

– Skilled need • Rehab, IV medications, wound care, etc

– Covers 100% for first 20 days, then pt has copay of $144.50/day.

• Many use this for end of life care – Medicare hospice benefit does not pay room/board

Arch Intern Med. 2012 November 12; 172(20):1573-1579.


• Nearly 1/3 of those 65 and older receive SNF

level care in last 6 mo of life under SNF benefit

– 1 in 11 died while enrolled (most in first 30 d)

• Do care expectations match overall goals?

– Decline as inpatient may better reflect deteriorating

overall health

– Same needs indicating need for SNF are same

indicators for end of life trajectory



• At time of hospital D/C – Goals may not be clear

– Provider may not recognize end of life path

• Families face choice – $ for room and board with hospice VS Medicare

SNF benefit and relying on NH for EOL services



• Need for palliative care:

– End of life symptoms

• Pain, SOB, spiritual distress, CG burnout, grief

– NH residents have little access to PC

– Hospice in NH is variable

• But better with hospice than without

– SNF benefit does not provide depth of EOL

services

• Comfort care is NOT hospice care


Interdisciplinary Care

• Need to incorporate all “specialties”

– Physician/NP/PA

– Nursing staff

– PT/OT/ST

– Social Work

– Chaplaincy

– “Hotel Staff” (cleaning staff, admin, meal prep, etc)

• Involve and educate anyone who may be in contact with a

dying patient

International Journal of Palliative Nursing, 2006, Vol 12, No 5.

Advance Care Planning in SNF

• Examined the effect of social worker intervention on

advance care planning

• Controlled clinical trial

– 139 participants

– Intervention group: extensive education in ACP

– Control group: education in NY State law re advance

directives

JAGS. 53:290-294, 2005.


• Intervention group sig more likely to have preferences

documented for:

– CPR (40% vs 20%)

– ANH (47% vs 9%)

– Antibiotics (44% vs 9%)

– Hospitalization (49% vs 16%)

JAGS. 53:290-294, 2005.


• Study showed minimal evidence of physician initiated

ACP discussion

– Excluding specific discussion about CPR, physician

initiated discussion documented in only 5% in both

groups

JAGS. 53:290-294, 2005.


• 44 sentinel events in both groups

– 17% who died had CPR in Control Group

• 0% in Intervention Group

– 27% had 1 or more hospitalizations in CG


– 7% remained in SNF and received abx in CG


JAGS. 53:290-294, 2005.


• Residents in CG

– Significantly more likely to receive tx discordant with

prior stated wishes

– 18% received tx in conflict with prior stated wishes


JAGS. 53:290-294, 2005.

Comprehensive ACP Program

• Comprehensive program

– Education of SNF staff, resident and family

– Documentation of choices

• Care preferences for life threatening illness,

cardiac arrest, nutrition

– Associated with high family satisfaction and

lower service utilization

– Symptom management not addressed in this

study

JAMA 2000;283:1437-1444.

Early Stages of a QI Project

Collaboration between

UCSF and ABSMC

Background

• ABSMC had our own SNF for rehab in the Summit Campus in Oakland

• Closed about 1.5 years ago

• Now contract with 3 local SNFs

• Initiative for better collaboration between hospital and SNF – Monthly meetings with inpatient staff, admin and SNF

teams

– Identify areas of improvement

– Initiate QI projects

– Continual re-evaluation and improvement

Data Gathering Methods

• Meet with DON and determine who is eligible and meets criteria for Pall Care Needs – Interact 3.0

– About 31% of residents eligible

• 70 patients at initial eval

Criteria for Eligibility

• Diagnoses appropriate for hospice including extent of disease in: – CHF

– COPD

– Dementia

– Cancer

Criteria for Eligibility

• Those at high risk of actively dying who should be considered for comfort care – Freq ED visits/admits in last 6 mo

– Sudden, irreversible major decline

– 1°dx of met cancer with pain, poor fcn, no tx

– Semi-comatose or comatose w/o reversible cause

– Inability/difficulty taking oral meds

– Minimal po intake

– Mottling of extremities due to poor po intake or dehydration

Data Collection

• Use Minimum Data Set primarily – 28 total interviews so far

• 7 patients

• 21 families (family interviewed when pt unable)

• Interview process – Resident Interview Guideline

– Family Interview Guideline

– Interview transcription

• Qual-E tools

– Measures QOL of seriously ill pts

What has been found…

• Preliminary results:

• Very few residents/families know what a POLST is

• Many feel the absence of physician at SNF

• Families mostly feel informed

– Concerns that those who live far away do not know

what’s happening and they generally want more

aggressive care

What has been found…

• Families feel the need to advocate for care

• Families have good insight into challenging care

needed by pt

– Poor insight into extent of disease

• Families find fault in small things

– Food, environment, etc

– influences their overall satisfaction

Still a LOT to learn…

• Next steps – Meet with hospital admin

– Pall Care to visit and tour each SNF • See facilities, begin to establish how to work

together, set expectations

– Follow up pts who received PC consult in hospital

– Provide PC to pts identified in study • ACP

• Symptom control

• Communication/education of pt/family

• Education of SNF staff

Barriers

• VERY limited resources

– Likely will be 1 PC physician for all 3 SNFs who still

has a full inpatient clinical load

• Hesitation of admin to fund outpt program

– Need to demonstrate ROI

• Current lack of Interdisciplinary resources

– No Social Worker

To Be Continued…

• Still in the information gathering phase

• Suspect that this won’t really get off the ground

for a little while

• Open to any and all comments if anyone has

experience in PC at SNF

Documents

Palliative Care at SNF - PCQN · 2019. 12. 19. · Medicare SNF benefit in last 6 months of life •Entitled to 100 days of SNF care –After 3+ day hospitalization –Skilled need