Developing a Coordinated Plan of Care

Partnership in End-of-Life Care

Donna S. Williamson, BSN, RNC, CHPNPalliative Care Consultant/LTC FacilitatorMountain Home, Arkansas

Identify the benefits of developing a nursing facility/hospice partnership.

Assess whether care is being provided according to regulations.

Explain the steps in developing a coordinated care plan.

Identify the steps in implementing the care plan.

Identify problematic areas in developing a coordinated care plan.

Objectives

Is Hospice Needed in the Nursing Home?

What are your opinions of thisNH staff?Hospice staff?

Caregiver is inadequate

Caregiver is absent

Environment is unsafeThere is no provision in the Hospice Benefit for a

primary caregiver.The nursing facility can provide ‘room and board’

Hospice Needs the Nursing Facility When….

Physical symptoms are not controlled Resident is in a non-skilled bed Resident does not want to leave the facility Resident does not want aggressive care

Psychosocial issues exist Family in crisis Other residents grieving Facility staff grieving

Nursing Facility Needs Hospice When….

“There is no indication in the statute that the term ‘home’ is to be limited for a hospice resident. A resident’s home is where he or she resides. The facility is considered to be the beneficiary’s place of resident (the same as a house or apartment), and the facility resident may elect the hospice benefit if he/she also meets the hospice eligibility criteria.”

Section 2082, State Operations Manual

The Federal Government Recognizes the Relationship

What is the Benefit of Working Together?

Validation of care by an outside provider

◦CMS Quality Indicators are negative outcomes

◦Prevalent in the dying process◦Two of the three sentinel events are

common problems in the terminally ill resident. Dehydration Fecal impaction

Benefits of Partnership

Supporting Documentation

◦Hospice consent form: Resident elects to receive palliative care.

◦Physician terminal prognosis.◦Advance directives.◦Hospice team charting on quality

indicators.

Benefits of Partnership

Hospice expertise

◦Symptom control◦Psychosocial intervention◦Spiritual care◦Bereavement◦Resident and family support◦Dealing with ethical issues

Benefits of Partnership

How Do We Work Together?

Nursing Facility Surveyor Guidelines Hospice Guidelines Fraud & Abuse Alert Hospice Compliance Program

Regulatory Basis

Resident elects hospice benefit Hospice RN makes an initial visit performing

complete assessment Review physician orders to align with

palliative care plan Review assessment with MDS Coordinator

and begin development of care plan Sharing of Care plans Joint care plan coordination Document collaborative care planning

Hospice Admission Process

They are either...

◦A new admission to the facility

OR

◦A pre-existing resident

When the Resident Elects Hospice

Hospice must complete the assessment and care planning process within 48 hours upon admission.

Nursing facility has 21 days. Hospice can share hospice problem list and

care plan with MDS Coordinator.

New Admission

Nursing facility has completed MDS & Care Plan.

Complete a Significant Change in Condition form.◦ Prognosis of six months or less◦ Changed from acute to palliative care◦ No need to fill out future significant change forms as

resident’s condition deteriorates◦ MDS triggers a new problem list◦ New care plan reflects palliative care

Pre-Existing Resident

How Do You Develop a Coordinated Care Plan?

Develop a common problem list

All triggered problems do not require care planning

Problems may be identified that are not triggered

Determine Resident Problems

State Operations states:◦ “coordinated plan of care for both providers

reflects hospice philosophy.” Conditions of Participation for nursing

facility states: ◦ “the resident receives care and services to

attain or maintain the highest practicable physical, mental and psychosocial well-being.”

Most Common source of tension and confusion in the relationship.

Determine Probable Outcomes

Self-Determined Life Closure◦ Anticipating death, mentally competent residents will

have full autonomy to make decisions about how the remainder of their life is spent within the allowances of law.

Safe and Comfortable Dying◦ The resident will die free of distressing symptoms, in

an environment that does not aggravate or hasten dying.

Effective Grieving◦ The expression of grief eventually supports the

individual’s ability to adjust to their environment without the deceased & regain the ability to invest in other activities and relationships.

Hospice Outcomes

After the comprehensive assessment process is completed, the interdisciplinary team will be able to decide if…◦The resident has a troubling condition

that warrants intervention, and addressing this problem is a necessary condition for other functional problems to be successfully addressed;

◦Improvement of the resident’s functioning in one or more areas is possible;

Nursing Facility Outcomes

Improvement is not likely, but the present level of functioning should be preserved as long as possible, with rates of decline minimized over time;

The resident is at risk of decline, and efforts should emphasize slowing or minimizing decline, and avoiding functional complications (e.g., contracture or pain) or;

The central issues of care revolve around symptom relief and other palliative measures during the last months of life.

Nursing Facility Outcomes, cont.

Resident

Provision of Care Services

Outcomes

Negative Positive

Avoidable Unavoidable

Measuring Highest Practicable Functioning

Reflect Hospice philosophy Designate responsible provider Designate responsible discipline Establish when it will be done Change and update to meet the resident’s

needs

Determine Interventions

Is Hospice Making a Difference?

“Substantially all hospice core services (physician services, nursing services, medical social services, and counseling) must be routinely provided directly by hospice employees and cannot be delegated.”

“The hospice may involve the SNF/NF nursing personnel in assisting with the administration of prescribed therapies included in the plan of care only to the extent that the hospice would routinely utilize the services of a hospice resident’s family/caregiver in implementing the plan of care.”

Area of Confusion in the Regulations

Room and Board Services include:◦Performing personal care service◦Assisting with activities of daily living◦Administering medication◦Socializing activities◦Maintaining cleanliness of a resident’s

room◦Supervising and assisting in the use of

durable medical equipment and prescribed therapies

Room and Board Services

Requires the Professional Management of:◦Services of the Interdisciplinary Team◦Medication related to the terminal illness◦Medical supplies related to the terminal

illness◦Durable medical equipment◦Lab, x-ray, treatments, etc.◦Inpatient care for periods of crisis

Resident does not have access to Medicare Part A services and has limited access to Part B services

Hospice Prospective Payment

Follow the steps of the nursing process

Remember…Outcomes are clinically “unavoidable” only if…◦Accurately assessed◦Adequate care is planned◦The care plan is actually implemented◦The interventions are evaluated

periodically and modified according to the resident’s responses.

Assessment and Care PlanningJust the Beginning…

Documentation in the MDS for Resident #2, noted the resident to have a short and long-term memory deficit and moderate impairment of cognitive function.

Record review identified the resident was being seen by a psychologist for individual therapy three times weekly for behaviors.

The resident was also being seen by a psychiatric consultant for management of her behaviors and antipsychotic medications. The resident is not cognitively aware to receive and participate in this therapy.

Nursing Facility SurveyorDeficiency on a Hospice Resident

Resident #1◦ This resident is obese and has congestive heart

failure, cellulitis, edema, and stage-3 pressure ulcers.

◦ According to the outcomes of the care plan, she has nothing to worry about because all these problems are going to be controlled or reversed.

What’s Wrong with This Picture?

Resident #2 – This resident is mentally retarded and has just undergone a colon resection for advanced colon cancer.◦Problem: Alteration in thought process,

impaired decision-making, impaired cognition secondary to diagnosis of mental retardation.

◦Goal: Resident will be able to make safe and reasonable decisions regarding care needs with the assistance of staff through next review

◦ Intervention: Encourage resident to discuss reasons for inappropriate decisions and how they can be avoided in the future PRN.

What’s Wrong with This Picture?

Resident #3-This resident has cancer of the brain and is having seizures◦Problem: Weight is above ideal weight.

Family and resident are often non-compliant with diet. PO intake varies.

◦Goal: Resident will be free of weight gain from weight of 228 lbs. by next review.

◦Interventions: Sugar substitutes, skim milk with meals, encourage family to bring in healthier low-fat snacks.

What’s Wrong with This Picture?

Resident #4-The care plan reads: Notify hospice, without any other interventions for the hospice team.

Resident #5-This care plan has a hospice portion that is stapled to the nursing facility care plan.◦Goal: Provide a safe and comfortable

environment conducive to the death and dying process in which the physical, spiritual and psychosocial needs and symptoms will be addressed and resolved, and resident will die in a supportive, care-giving system in accordance with their wishes.

What’s Wrong with This Picture?

? Regulator/Surveyor ? Fiscal Intermediary ? Nursing Facility ? Resident ? Family

Who Are We Serving?

Resident and Family

Questions & Answers