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Today’s Webinar will begin at 11:30AM

Today’s Webinar will begin at 11:30AM. 6/27/12. Introduction. More Introduction. Please do not put your phone on hold; use the mute function or *6 Please type questions or comments into text box If time permits, we will open up the phone lines at the conclusion of the presentation.

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Today’s Webinar will begin at 11:30AM

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  1. Today’s Webinar will begin at 11:30AM 6/27/12

  2. Introduction

  3. More Introduction • Please do not put your phone on hold; use the mute function or *6 • Please type questions or comments into text box • If time permits, we will open up the phone lines at the conclusion of the presentation

  4. Peg Nelson, NP, ACHPNachpnDirector of Palliative and Pain ServicesSt. Joseph Mercy Oakland

  5. Our Palliative Care Joint Commission Journey Peg Nelson, NP, ACHPN Director Pain and Palliative Care Services

  6. The Journey of Creating Peace and Healing at SJMO • Began in late 1990s when we were attempting resuscitation on 60-70% of the patients who died • Only could find 30% patients with any pain scores at all documented • Of those we could find – average pain score when palliative care was consulted: 8/10. • Demerol was number one drug used for pain

  7. First Work • Understanding the suffering at SJMO • Learning from hospice, ethics and local palliative programs • Institute of Medicine (IOM) Report on End of Life • Institute of Healthcare Improvement • SUPPORT Trial

  8. Mercy Supportive Careest. 1999 • MSN and oncologist • Harpist • Healing touch practitioner • Lots of nurses, case managers and an administration who supported palliative care and pain management

  9. Key Processes to Achieve Goal • Assess and understand the suffering. • Educate, develop and inspire staff and volunteers to deliver excellence in pain and symptom management, ethics, palliative and end of life care management. • Create systems of care across the continuum that make it easier to deliver quality care and support staff and volunteers who deliver care. • Create access for all who are suffering.

  10. Head: Knowledge, Competence *Conscience: “Know what to do and the right thing to do” Hands: Process, Systems*Culture: “How to do it so all are served” Heart: Compassion, Humanity *Presence: “Doing it with enduring love” TOTAL BODY MODEL FOR SUCCESSFUL PALLIATIVE SERVICES at SJMO*

  11. Trinity Health Vision for Palliative Care In Trinity Health everyone impacted by illness will have access to comprehensive palliative care and experience care excellence through the prevention and relief of physical, emotional, social and spiritual suffering.Compassionate and holistic care will be provided throughout the journey of living and dying.

  12. We Studied Our Own Experience • Through family post-death interviews • Staff assessment of the patient and family dying experience and their own suffering and needs • Post-death chart review

  13. Our Response • Created a new culture, where suffering is not acceptable with focus on continuous improvements in patient care. • Provide 24-hour pain, palliative and spiritual support for patients and their families. • Provide team members (staff and volunteers) with the training and tools necessary to provide excellence in end of life care. • Multiple entry points for receiving pain and/or palliative and/or hospice care.

  14. Interventions • Required 5 hour pain/palliative class • Extensive resident and nurse end of life education • Comfort Care order sets • Mentoring staff • One patient at a time – the world and culture changed

  15. Pain Scores • At time of consult for palliative care: • 2000 – 7.8/10 • 2001 – 6.3/10 • 2004 – 3.4/10 • 2005 – 2.4/10….and continues to this day • Which was one of the biggest reasons we won the • Circle of Life Award in 2006

  16. COMFORT CARTS“Crash Carts for the Dying” Creation of a loving and peaceful environment – we call sacred space • CD Player and many CD’s • Bibles, Korans • Example of Prayers • Grief Information • Funeral Home Listings • Information on physical, emotional and spiritual changes at end of life • Sympathy cards/Dove Sign for Door • Hand Casting Materials • Love Blankets “This is a love blanket, it is a symbol of the love shared in ____’s life. We hope it brings him comfort now and after he dies please take it with you and may it help you in the days to come.”

  17. Early Milestones • CALL CARE Project – Supportive Care of the Dying Coalition – one of 11 sites in 2001 funded by Robert Wood Johnson – to implement palliative outpatient services • $150,000 donation from family of patient to expand services - 2002 • $200,000 Trinity Health Mission grant to expand palliative care services for the poor in Pontiac 2005

  18. Comfort Companions • Common top two fears people have at end of life are: • Pain not being controlled • Dying alone • Our Comfort Companion Program helps to ease these fears by: • Providing a loving presence for patients. • Providing support and respite for families. • Assurance that patients are safe from distressing symptoms.

  19. Comfort Companions Bring: Since 2005, 468 patients served, and over 9824 hours of service • Presence • Kindness • Assurance of physical and emotional comfort • Notifies staff if needs arise • Communicates with family • Soothing Environment • Sensitivity to culture and spiritual needs • Love

  20. Bedside Sacred Ritual in Ambulatory Surgery

  21. Life in the Emergency Department and death

  22. Palliative Care Team *Palliative Board Certified • NP Director* • Medical Director* • Bereavement/Volunteer Coordinator • Nurse Practitioners* • Music Practitioner/Harpist • Healing Touch/Massage Therapist • Chaplain • Respiratory Therapist • Case Manager • Dietician • Pharmacy • Wound/Ostomy Nurse • Utilization Review • Homecare/Hospice • Oncology Nurse • Social Work • Internal Medicine

  23. We aspire to meet the National Consensus Project’s clinical guidelines for quality palliative care.And use CAPC tools and consensus recommendations

  24. 8 Domains of Quality Palliative Care • Processes and Structure of Care • Physical Aspects of Care • Psychological and Psychiatric Aspects of Care • Social Aspects of Care • Spiritual, Religious and Existential Aspects • Cultural Aspects of Care • Care of the Imminently Dying • Ethical and Legal Aspects of Care

  25. We are seen as the pain and palliative care team • Reason for consultation: • 40% physical and psychological symptom management • 40% Clarification of goals, advance care planning, family support and communication • 20% End of life, withdrawal of life support and transition to hospice

  26. Practical Aspects • Scattered-bed Consultation Service (Oncology/palliative unit sees most expected end of life) • 24/7 with weekly team meetings • Typical Social Worker role is shared by Unit based case manager, social work, unit RN and palliative clinicians. • Oversight by Pain Steering committee which reports to Medical Staff Quality and the Quality and Safety Board of Directors

  27. Palliative Care Snapshot(one month – 31 patients) Primary Diagnosis • Cancer – 38% • Heart Disease – 19% • Respiratory – 16% • CVI – 10% • Kidney – 6% • HIV/sepsis/other – 11% Disposition • 34% hospice • 19% home • 15% ECF • 3% rehab • 29% died

  28. Palliative Care Snapshot(one month – 31 patients) • ICU LOS – 22% (median 3 days, only 1/31 had LOS >7 days) • Hospital LOS – range 2-61, median 7 days • LOS on service – range 1-36, median 4 days • Race • 83% White, 13% Black, 4% Hispanic

  29. Palliative Care Service • Palliative census – range 2 to 10 per day (average 5) (NP bills 110-190 visits/month), average 32 palliative consults/month • Referrals for bereavement support, comfort massage, No one dies alone support, life review assistance, chaplain and healing touch can be ordered by RN • Consultation for goal clarification and/or symptom management ordered by physician

  30. Of Patients who died • All died in private room • One patient died alone • Pain score before death – average <1/10 • Range 0-3/10 • No patients had CPR at death

  31. Expense/Cost Avoidance/Revenue • Total Expense $540,000/year • FTE’s 4.8 • Cost Avoidance based on CAPC impact calculator – $920,000* (based on volume we are more productive than most mature programs) • Revenue • NP billing: $230,000 - $99,000 = $131,000 • Donations: $11,390

  32. Current Performance Measures • Spiritual Assessment (Process and Outcome) • Non-pain symptom assessment (Process) • Pain reduced to 4/10 or acceptable level in 24 hours (Outcome) • Family was given appropriate information in order to make decisions regarding loved one (Outcome) • (Previous outcome for family – felt patient died comfortably and felt supported)

  33. Quality Metrics

  34. Commitment to Support of Others – since 2005 we have mentored: • 131 Hospitals, ECFs, hospices and corporate/health systems • 64 individual Clinicians • 81 new No One Dies alone programs • >2200 clinicians attended pain/palliative classes • 30 churches and over 300 parish nurses • 9 Colleges/Universities

  35. Mature Palliative Care Program Experienced Clinical Leader/Director Experienced Medical Director Senior Leadership Support Certification in Palliative Care – hospital priority Keys to Successful Certification

  36. Developed written ‘Scope of Practice’ Performance Improvement Plan – formalized in 2011 Performance Measures Submitted Education binders based on domains Team orientation manuals End of Life/Bereavement Policy Documents Prepared

  37. Rehearse Tracers/Mock surveys were helpful Speak as an interdisciplinary team, the survey will be team focused Prepare and demonstrate 4 months of data for review at survey Focus on National Consensus Guidelines, CAPC, or National Patient Safety Foundation Utilize published tools and resources Imperative to disseminate educational materials Lessons Learned

  38. Role of chaplain and social worker Performed detailed tracers on patients Job descriptions for practitioners Scope of practice shared among members Non-pain assessments and documentation of assessment Lessons Learned

  39. The Joint Commission Disease Specific Certification Guide http://www.jcrinc.com/Accreditation-Manuals/PCC12/4032/ Center to Advance Palliative Care http://www.capc.org/about-capc National Consensus Project http://www.nationalconsensusproject.org/ Resources

  40. Center to Advance Palliative Care Palliative Care Consultation Service Metrics: Consensus Recommendations http://online.liebertpub.com/doi/pdfplus/10.1089/jpm.2008.0178 CAPC Certification Guide http://www.capc.org/palliative-care-professional-development/Licensing/joint-commission/tjc-guide-2011.pdf Resources

  41. The Joint Commission (TJC) Advanced Certification for Palliative Care Programs http://www.capc.org/palliative-care-professional-development/Licensing/joint-commission Resources

  42. Peace and healing is sacred

  43. Contact information: Peg Nelson 248.858.3399 nelsonp@trinity-health.org

  44. Notes will be on our website

  45. Thanks for joining us today!

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