SCHERVIER NURSING CARE CENTER Palliative Care in Long

SCHERVIER NURSING CARE CENTER
Palliative Care in
Long-Term Care:
Good Practices and
Tools for Success
Wadie Utkovic, LCSW
Social Work Supervisor, Schervier
Nursing Care Center, Bronx, NY
1
Bon Secours New York:
Schervier Nursing Care Center
364 beds (292 LT and 72 Sub-acute) in the
Bronx, NY
Why are we here?
Each year in the U.S., 31% of elders who
die, do so in hospitals.
- Expensive and often unnecessary treatments
- Treatments often cause discomfort and
distress
- Often surrounded by strangers
- Staff ill-equipped to deal with death
- Little support for the family
2
Our Mission
The mission of the Bon Secours Health
System is to bring compassion to
health care and to be
Good Help to those
in need, especially
those who are poor
and dying.
Looking Back to August 2011
-
15 out of 292 long term residents on palliative care (5%)
Palliative care committee meeting infrequently
Focus and priority was not on palliative care
Undergoing staff changes
Uncertainty of the meaning of palliative care
3
What happened?
-
Palliative Care was made a system priority in FY12 (Sept ‘11 – Aug ’12)
-
Statistics on palliative care were included in monthly dashboard reports
-
Administrative focus was on Palliative Care
-
Director of Social Work awarded 2 year
Leadership Fellowship in Palliative and
End-of-Life Care at New York University
-
Palliative Care Information Act
-
Palliative Care Access Act
Process Changes Made
- Established Regular meetings of the Palliative Care Committee,
with new committee chair
- Reviewed and Revised policy and procedure on Palliative Care
- Within this P&P, established each discipline’s role in what they
did differently for residents on Palliative Care (nursing,
medicine, social work, dietary, recreation, pastoral care,
rehabilitation, volunteers…)
- Educated staff on the differences of goals of care
- Educated residents and families of the differences of goals of
care (resident and family council meetings)
4
Process Changes Made
- Began presenting palliative care concepts and philosophy at
new employee orientation
- Listed all residents on palliative care on daily census report
- Included discussions on palliative care in daily morning report
on residents who were failing (weight loss, pneumonia, repeat
hospitalizations)
- Funeral planning and burial guide
- Set annual performance goals with palliative care measures
- Unit tracking of advance directives by social work
Advance Directives Tracking
Month
2North
HCP
TF
2South
DNR
HCP
TF
3North
DNR
HCP
TF
3South
DNR
HCP
TF
4North
DNR
HCP
TF
4South
DNR
HCP
TF
5North
DNR
HCP
TF
5South
DNR
HCP
TF
DNR
Sept
85%
1.00
61%
78%
2.00
68%
48%
2.00
70%
75%
5.00
55%
70%
2.00
70%
65%
5.00
63%
42%
2.00
70%
64%
4.00
56%
Oct
88%
1.00
67%
83%
2.00
65%
52%
1.00
64%
80%
5.00
58%
70%
2.00
70%
69%
4.00
60%
47%
2.00
78%
60%
4.00
58%
Nov
88%
1.00
67%
88%
2.00
68%
51%
1.00
70%
80%
4.00
58%
70%
2.00
73%
79%
4.00
69%
47%
2.00
73%
62%
3.00
58%
Dec
88%
1.00
67%
88%
3.00
68%
58%
1.00
76%
83%
3.00
60%
70%
3.00
73%
75%
4.00
72%
52%
2.00
70%
56%
3.00
74%
Jan
88%
1.00
67%
88%
3.00
68%
55%
1.00
76%
89%
3.00
61%
67%
2.00
73%
74%
4.00
74%
56%
2.00
70%
55%
2.00
70%
Feb
84%
1.00
55%
85%
2.00
60%
55%
1.00
78%
89%
3.00
61%
67%
2.00
70%
74%
3.00
77%
45%
2.00
70%
55%
2.00
73%
Mar
82%
1.00
56%
88%
2.00
60%
51%
1.00
79%
88%
2.00
65%
70%
1.00
76%
74%
4.00
77%
42%
2.00
73%
55%
2.00
75%
Apr
85%
1.00
55%
88%
2.00
60%
50%
1.00
81%
85%
2.00
60%
70%
1.00
82%
77%
4.00
85%
46%
2.00
70%
55%
2.00
75%
May
82%
1.00
58%
88%
2.00
63%
50%
1.00
84%
85%
1.00
65%
70%
1.00
85%
74%
4.00
85%
45%
2.00
70%
55%
2.00
75%
Jun
85%
1.00
57%
88%
2.00
61%
52%
0.00
81%
83%
1.00
64%
70%
1.00
85%
74%
4.00
85%
47%
2.00
67%
58%
2.00
71%
Jul
91%
1.00
55%
90%
2.00
59%
48%
0.00
88%
80%
1.00
65%
64%
1.00
82%
72%
4.00
85%
42%
1.00
70%
53%
3.00
75%
Aug
91%
1.00
56%
90%
2.00
59%
48%
1.00
85%
85%
1.00
67%
64%
1.00
82%
72%
4.00
85%
43%
1.00
70%
52%
3.00
78%
60%
87%
63%
51%
78%
84%
62%
69%
77%
73%
76%
46%
71%
57%
86%
70%
Avg
YTD
5
Program Components
- Use of Palliative Care
Order Sheet to help guide
Clinical Staff interventions
Allows staff to take a fresh look
at a resident, and build a new
plan of care (vs. editing an
existing plan of care)
Program Components
- Identification of direct palliative care admissions on admit sheet
- Care plan meetings asap with resident and family
- Daily visits by pastoral care staff
- Private room whenever possible
- Flexibility in meeting family “special
requests”
- Accommodations for family members
to stay overnight
6
Program Components
- Post-death condolence card from all unit staff
- Sharing of resident wake/shiva & funeral arrangements with
staff, with at least one staff member attending
- Bi-annual memorial service
with slideshow
Results (Sept ‘11 to Aug ‘12)
Residents on palliative care went from 15 (5%) to 72 (25%)
Residents with HCPs went from 65% to 69% (6% increase)
Residents with DNRs went from 64% to 73% (14% increase)
7
Results (Sept ‘11 to Aug ‘12)
Residents with feeding tubes went from 24 to 14
(42% decrease)
WOW!
“About one third of U.S. nursing home residents with
advanced cognitive impairment have feeding tubes. In this
setting, such tubes can cause discomfort and have no
demonstrable health benefits"
(JAMA, July 2, 2009, pp. 73-80).
Results (Sept ‘11 to Aug ‘12)
30 Day re-hospitalization rate went from 17.4% to 15.2%
(13% decrease)
8
Increased Partnerships
-
Columbia Presbyterian Medical Center
NYU Medical Center
Calvary Hospital
Montefiore Hospital
NCBH/Jacobi Hospital
Mt. Sinai Hospital
Riverdale Neighborhood House
Direct Palliative Care Admissions
 Since outreach began in January 2012, we have had
52 direct palliative care admissions from hospitals
 Performance improvement project
underway to analyze results to
improve outcomes
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Other Opportunities
 Obtained $103,000 grant from the Fan Fox & Leslie R
Samuels Foundation for a Palliative Care Transitions
Coach – started in February, 2013 and has brought
almost $500,000.00 in revenue to the facility
 Social Work intern program with MSW students from
NYU to provide further support to residents on palliative
care and their families
Other Opportunities
 Palliative care is an integral part of our daily clinical
discussions and strategic planning.
Clinical Leadership Vision Statement:
“Our vision is to be a world class, faith based organization;
a leader in providing exceptional rehabilitative, palliative,
dementia and long-term care. We value clinical excellence,
research, and evidence-based practice, achieved through
collaboration and innovation, to enrich the quality of life of
those we serve”.
10
Role of Hospice in Palliative Care
- 1:1 time with home health aide
- Help with symptom management
- Additional family support
- 1 year bereavement support
Case Study
Joan
-
85 year old woman, admitted to the facility in 2004
On admission, post CVA, dysphagia with a feeding tube
After rehab, could eat normally and feeding tube was removed
Very active within the nursing home, especially involved in daily
mass, and was resident council president
Used to be a Sears catalogue model, loved wearing red lipstick
Increased falls, health was deteriorating, wanted her independence
Early September, suffered another CVA, rendering her incapable of
speech, bedbound and unable to swallow
Daughter (health care proxy) initially wanted feeding tube placed
11
Take Aways
1) Include care of the dying in your
mission statement, or at least in your
vision statement
2) Ensure you have at least 2
champions: one with decision-making
power, and one with the passion for
implementation
3) Set goals you want to achieve
4) If you measure it – it will change
Take Aways
5) Take a Fresh Look – create a new plan,
don’t revise an old one
6) Incorporate discussions on palliative
care on a DAILY basis
7) Communicate Results
8) Have a WOW slide
9) Forge good partnerships
10) You can’t win them all – but you can
empower, guide and support
12
Thank you!
Questions?
[email protected]
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