problems identified in the end of life community in concord
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8/9/2019 Problems Identified in the End of Life Community in Concord
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Problems Identified in the End of Life Community inConcord, North Carolina
A complete community assessment has been performed including key informant interviews,
epidemiology/demographic research, attainment of information regarding health care services,
and assessment of cultural and history background information. This information was collected
and utilized to identify end of life key problems, objectives and interventions related to the
28027 community. Unfortunately, the majority of statistics and research findings collected
related to either North Carolina or Cabarrus County, as a whole, limited information regarding
the actual zip code was present. However, these findings seem to be correlate to the health issues
related to the end of life population observed in the 28027 area. In order of priority, the major
health concerns of the end of life population in 28027 are: lack of utilization of end of life care
due to insufficient knowledge and availability of information about services, safety, and
transportation. The information presented below represents why these are the major issues of this
population and solidify our arguments towards the three main health concerns for this population. In our key informant interview with both Janice Honeycutt and Coney Rarey, lack of
education regarding end of life services was indicated as the primary issue with this population.
Both, Ms. Honeycutt and Ms. Rarey, indicated that initiatives were in place to increase
awareness of hospice and palliative care services and increase utilization of these services both at
home and in the hospital setting, however, barriers are still present.
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1. Lack of Utilization of End of Life Care Due to Insufficient Knowledge and
Availability of Information about Services
Three components cont ribut e to t hi s i ssue in t he Concord Community:
o No information visible in the community related to end-of-life care and resources
o Deficiency in provider knowledge about benefits of end-of-life resources evidence bylate referrals to end-of-life careo Community misconceptions about the purpose and benefits of end-of-life care (fear
associated with utilization of these services)
In 2008, approximately 35.4% of those served by hospice died or were discharged inseven days or less (National Hospice and Palliative Care Organization). This number reflects the pervasive problem in end-of-life care that is seen on a national level and isalso evident in the Concord community. There are many barriers to utilization of end-of-life services, but lack of education of healthcare professionals and the community as a
whole is one of the biggest contributors.
Number of Medicare-certified Hospices and Program Payments, by State, 2007
State # of Hospices
# of
persons
# of Hospice
Days
Average Length of
Stay
Program
Payments ($
Thousands)
NC 82 32,086 2,394,987 75 336,582
Source: Centers for Medicare & Medicaid Services, Health Care Information System
Healthcare provider¶s knowledge and communication regarding end-of-life care plays a key role
in hospice and palliative care utilization because they are the gatekeepers to patients obtaining
these services. Many barriers to end-of-life care by healthcare providers relate to incorrect
knowledge, unfavorable attitudes toward hospice and deficient knowledge of palliative medicine.
Research indicates that many healthcare providers feel uncomfortable regarding the care of
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terminally ill patients and the vast majority correlated this deficiency with the lack of education
and training (Forcina Hill, 2005). These reports were supported by a 2004 study that found only
126 medical schools in the United States offered courses in palliative care to students (Forcina
Hill, 2005). In addition, one study found that only 12% of practicing physicians are aware of the
prognostic guideline set forth by the National Hospice and Palliative Care Organization and 84%
are unable to recognize appropriate diagnoses based on these guidelines (Forcina Hill, 2005).
This problem is not unique to medical staff, nurses as a whole are also considered deficient in
knowledge related to hospice and palliative care. In 2002, only 3% of nursing schools reported
having a course dedicated to end-of-life care and less than 0.5% of nurses are certified in
palliative care (Forcina Hill, 2005). Ninety eight percent of nurses interviewed in the above
mentioned study reported that end-of-life care was important but stated they felt ill prepared to
effectively provide this care (Forcina Hill, 2005).
In addition to lack of basis knowledge regarding hospice and palliative care option by
physicians, many are reluctant to give patients a diagnosis of six months or less and have a great
deal of discomfort discussing a negative prognosis with a patient. Physicians overestimate life
expectancy of their patients (believe that the patient will live longer than six months). In one
study, 59% of 147 physicians reported that making a prognosis of remaining time to live was the
most frequent barrier to discussing the hospice option of care (McGorty & Bornstein, 2003). In
the same study of 147 physicians, 6% reported discomfort in telling patients about dying issues
and sixteen percent felt uncomfortable discussing the patient¶s terminal diagnosis (McGorty &
Bornstein, 2003). This inability make a diagnosis of six months or less and to discuss death and
dying with patients decrease quality of life of dying patients and decreases the likelihood this
population will seek out and utilize these hospice and palliative care services.
This trend of lack of knowledge with end-of-life care options was noted in the Concord
community. During our key informant interviews, it was stated that the average number of days
patients are on hospice services is less than two weeks. Hospice and Palliative Care of Cabarrus
County contributes this statistic in part to the lack of promotion and understanding of hospice
and palliative care services by healthcare providers. Patients are unable to reap the benefits of
hospice services when a referral is made at a time when the patient only has a few days to live.
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Therefore, few in the community understand the benefits and breadth of end-of-life services
available.
Education of the end-of-life community and their family members is a large hurdle to increasing
the utilization of hospice and palliative care services in Concord. Many patients are reluctant to
hear about end-of-life care options, because they feel that just by accepting end-of-life care
options they are inherently giving up all hope. This reluctance extends to caregivers and family
members who are unwilling to accept a terminal diagnosis. Many fears could be addressed with
proper community education and outreach by the end-of-life care community. Community
outreach and presence of end-of-life services was not evident during the windshield survey
conducted of Concord. Hospice and Palliative Care of Cabarrus County identified this as an issue
during the key informant interview. This organization noted that many satisfaction surveys sent
out after a patient passes away frequently contain the comment that ³We wish we would have
known about your services earlier.´
Education regarding the variety of services is lacking in this community. Many of the outreach
programs currently in place are not focused on educating potential patient about the
multidisciplinary services offered by hospice and palliative care. These programs mainly focus
on bereavement services. In addition, the benefits of these services are often not promoted. This
lack benefits focused education does nothing to dismiss many of the negative stereotypes and
fears the end-of-life community has about receiving hospice services. Many never learn that
hospice care allows terminally ill patients and their families to remain together in the comfort
and dignity of their homes during the patient¶s final days.
Until healthcare providers, patients, and families in the Concord community become more
comfortable talking about death and the dying process, hospice will remain marginalized as an
excellent option for accessing supportive services for the end-of-life community during an
extremely difficult time.
2. Safety
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o safety in the home-many rural homes
o no sidewalks or cross walks
o older homes not built to accommodate medical equipment o Isolation in homes
o Availability of appropriate care taker
Community AssessmentThroughout observation of the community many risk factors were evident that indicated the end
of life population was at risk for safety issues. One of the major initiatives of Hospice and
Palliative Care of Cabarrus County is to reduce falls because of the increase in falls in the end of
life population; thus, falls are the major safety focus of the facility. As a result, home safety to
prevent falls is one of the major goals of the facility. We recognize that many of our patients live
with family members who are not there during the day, thus, they have to take care of themselves
and as a result, an increased number of falls occur. Additionally, many homes seen throughout
the community windshield survey were older homes, thus the construction of the homes is not as
reliable and sturdy. Many of these homes lacked handicap accessibility and assistance devices
for the older community. Many of the stores in the area lacked handicap accessibility, when
stairs were present no ramp was available for wheelchairs. Handicap parking was accessible, but
far away from the entrance of the store/facility, etc. In addition, many roads through the
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community were narrow and night lighting was limited, therefore, this increases the elders¶
chances of getting in a wreck. Throughout this community, sidewalks and crosswalks were
limited, thus increasing the incidence of death if elders were to attempt to walk on busy roads.
When observing the area in and around Popular Tent Road, Derita Road, and Harris Road many
of the homes were secluded and far away from one another, thus, if help was needed it would be
difficult to obtain.
What is a Fall?
A fall is often defined as ³inadvertently coming to rest on the ground, floor or other lower level,
excluding intentional change in position to rest in furniture, wall or other objects´ (Yoshida,
n.d.).
Incidence
Falls are the leading cause of injury related visits to the emergency department in the United
States and the primary cause of accidental deaths in individuals over 65 years. Falls account for
70% of actually deaths in persons 75 years of age and older (Fuller, 2000). Overall, the elder
who represent approximately 12 percent of the population account for nearly 75 percent of death
related to falls. Both children and elder persons are at high risk for falls, however, elder persons
who fall are ten times more likely to be hospitalized and eight times more likely to die as a result
of a fall (Fuller, 2000).
Through evidence and research, findings show that among community-dwelling older people
over 64 years of age 28-35% fall each year (Yoshida, n.d.). For those 70 years of age,
approximately 32-42% falls each year (Yoshida, n.d.). Thus, the frequency and mortality rate of
falls increases with age and frailty level. (Yoshida, n.d.). Consequently, the injury rate for falls in
individuals older than 85 years of age is the highest among the elder accounting for
approximately 171 deaths per 100,000 persons. (Fuller, 2000).
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Evidence also indicates that elders living in nursing homes fall more often than those who live in
the community, thus approximately 30-50% of those living in long-term care facilities fall each
year and 40% of them fall more than once (Yoshida, n.d.).
Increases with age from 35:1000 for people age 65-69 to 76:1000 for people age 80 and over
(Yoshida, 2000). Those 65 years and older the rate of falls serious enough to limit activity was
47.7:1000 (Yoshida, n.d.). Additionally women are more likely to fall than men in all age groups
over 65 except those 75-79 years of age; however, the exact cause is unknown (Yoshida, n.d.).
Elders who experience falls experience many health issues as a result. Their hospital stays are
nearly twice as long as those who have never fallen, their ability to perform activities of daily
living decline, and there is also a decline in physical and social activities (Yoshida, 2000). Falls
can be a sign of a nonspecific acute illness. Additionally, they can lead to major injuries such as
head trauma and dislocations (Yoshida, 2000).
Trends in Fall Related Fatality Rate
Rates for men and women increased between 1993 and 2003. The men¶s fall rate increased 45%
and the women¶s fall rate increased 59% (Yoshida, n.d.).
Risk Factors
Falls are the result of demographic, physical and behavioral risk factors. Among those who
suffer from falls in the US, white men, have the highest fatal fall rate followed by white women,
black men and black women. Research shows that falls are 33-60% higher among Caucasians
than any other race (Yoshida, n.d.). Additionally, socioeconomic status plays a significant role
on the incidence of falls. Those who have limited access to health and social services, low
income, little education, and poor housing environments are at a higher risk of suffering from
falls. Studies also show that women who are socially interactive experience less falls than those
who are not (Yoshida, n.d.).
Summary of Biological Risk Factors (Yoshida, 2000)
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Age
· Fall-related mortality rates increase exponentially with age, with the greatest increase after age.
Sex
· Women have an injury rate 40-60% higher than men of similar age do.
· Women are 2.2 times more likely to suffer fractures as a consequence of falls.
Medical Conditions
· Diabetic women are 1.6 times more likely to fall and twice as likely to suffer fall-related
injuries as women without diabetes.
· Approximately 38-68% of Parkinson¶s disease patients experience falls due to gait
disturbances.· Depression is associated with a 2.2 fold increased risk of falling but the direction of causality is
unknown.
· Women with mixed incontinence are three times more likely to fall as women who do not have
this condition.
· Persons with Alzheimer's disease are twice as likely to fall as people of the same age without
this disease.
Physical Conditions
· Muscle weakness is associated with an almost five times greater risk of falling.
· Visual impairment is associated with slowed reaction time, increased body sway, and a 2.3
times increased risk of multiple falls.
· Cognitive impairment from dementia and delirium is associated with increased risks ranging
from 2.0 to 4.7.
· Foot problems, such as severe bunion, toe deformity, ulcer and deformed nails, are associated
with a two-fold increased risk of falling.· Low BMI and weight loss are associated with low bone mineral density and an increased risk of
fall-related fractures.
Result of Falls
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³Falls can result in fractures (64%), fear of falling (44%) and hospital admissions (32%), and
reduced quality of life. Falls can also result in a ³post fall syndrome´ that includes dependence
(32%), loss of autonomy (14%), confusion (22%), and immobilization (4%), depression (2%),
and restrictions in daily activities. Falls are often considered a contributing reason for admission
to a nursing home" (Yoshida, n.d.).
3. T ransportation
y Few options for patient to get transpiration to medical appointments
Windshield Survey/Community Assessment
While performing the windshield survey it was evident that there was limited transportation
available to community residence. Sidewalks were limited, no taxis were noted, no public buses
were noted, and no access to car pool or other resources were available. Although, the key
informant interviewees did not recognize transportation as an issue, research and statistics of the
county indicate that indeed it is an issue for the elderly population and particularly those of theend of life population who have limited ability to drive themselves. Additionally, due to the
high-paced community and need to maintain incoming revenue families are no longer at home
with their sick relatives thus limited means of transportation via family/friends is also limited.
Available Resources/Limitations
1. Cabarru s County Tr anspor tat ion S ervice s
The purpose of this bus service is to provide eligible candidates transportation to healthcare and
improve their quality of life. The service can be used by the elderly for healthcare appointments
and pharmacy (for prescription pick-up only).
Limitat ions:
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that were well lit and covered from the weather. Residents would like to see more
comprehensive, community-based services provided where they can access all types of needed
healthcare, from preventive, urgent care, and adult medicine within the same vicinity.
Statistics (Cabarrus Health Alliance, 2004):
Telephone Survey results regarding most unmet transportation needs:
1. Transportation to helping agencies (2.6% of respondents, approximately 3,700 individuals).
2. Transpiration to health care services (2.4% of respondents, approximately 3,500
individuals).
Among the highest percent of those interviewed and reported an unmet transportation
need were individuals 65 years and older.
Over 12% of individuals 65 years and over reported an unmet need for transportation to health
care services.
Over 10% of individuals 65 years and over reported an unmet need for transportation to social
services.
Over 7% of individuals 65 years and over reported an unmet need for transportation to the
pharmacy.
Overall, these percentages were higher than any other single age group surveyed.
Telephone Survey results:
Over 4,500 (8.4%) households in Cabarrus County do not have a vehicle available for use.
The largest unmet transpiration need is transportation to helping agencies with over 3,700
(2.4%) individuals affected.
The second largest unmet transportation need is transportation to health care services with
over 3,500 (2.4%) individuals affected.