Hospice Case Management

Defining Quality

Defining Quality

Hospice Case

Management

Kindred Healthcare, Inc.

Objectives

At the end of the session participants will be At the end of the session, participants will be able to:

…Understand the regulations regarding oversight of the hospice plan of care by the RN Case Manager

…Understand the standards of practice for the hospice RN Case Manager

…Explain key components of the hospice RN Case

…Explain key components of the hospice RN Case Manager role

…Identify the educational components for training the hospice RN Case Manager

Regulations

„

418 56(a)(1) The hospice must designate

„

418.56(a)(1) The hospice must designate

a registered nurse that is a member of the

interdisciplinary group to provide

coordination of care and to ensure

continuous assessment of each patient’s

d f

il ’

d

d i

l

i

f

and family’s needs and implementation of

the interdisciplinary plan of care.

Regulations

„

Hospices are free to refer to the

di

t

i

th t

t

coordinator in a manner that meets

their needs, as long as there is an

individual identified as being

responsible for coordinating and

implementing each patient’s plan of

p

g

p

p

care

RN Case Manager works under the

supervision of the clinical manager

Regulations

„

Case Manager needs to have solid

„

Case Manager needs to have solid

knowledge of the biological,

psychological and spiritual issues of

terminally ill patients and their

families

families.

Regulations

C

M

t

d

t

„

Case Manager acts as an advocate,

negotiator, and leader when dealing

with the varied members of the IDG,

the patient and the patient’s family.

Regulations

„

The registered nurse has the necessary

„

The registered nurse has the necessary

medical and interpersonal background to

meet the demands of the coordinator

position in a way that no other discipline

does.

…The nurse is designated as the coordinator of the plan of care, or Case Manager

Regulations

Shift of focus from a reactive

to a proactive

patient/family centered

approach

Scope and Standards of Practice

„

Developed by the Hospice and Palliative

„

Developed by the Hospice and Palliative

Nurses Association

„

Authoritative statements

„

The standards identify the responsibilities

for which the hospice and palliative nurses

o

c

e osp ce a d pa a

e u ses

are accountable.

Standards of Hospice and Palliative

Nursing Practice

„

The standards of practice are divided into

two sections:

…Standards of Practice

…Standards of Professional Performance

Standards of Hospice and Palliative

Nursing Practice

The GOAL of the hospice nurse is to

promote and improve the quality of life:

„

Aggressive efforts to relieve pain

Standards of Hospice and Palliative

Nursing Practice

„

Through appropriate care individualized

„

Through appropriate care, individualized

for one’s specific needs, the patient and

family are able to attain a degree of

mental, emotional, and spiritual

preparation for a death that is satisfactory

h

to them.

„

Help people live until they die.

Standards of Hospice and Palliative

Nursing Practice

„

In all aspects of care the hospice and

„

In all aspects of care, the hospice and

palliative nurse demonstrates:

critical thinking

analysis

clinical judgment

Standards of Hospice and Palliative

Nursing Practice

„

Optimize the comfort and dignity of

„

Optimize the comfort and dignity of

patients

„

Provide care that is consistent with patient

and family needs and goals, with patient

needs and goals as priority.

„

Ensure that patient care is furnished in a

safe and effective manner

Standards of Practice

„

Follow the nursing process:

„

Follow the nursing process:

…Assessment …Diagnosis …Outcome identification …Planning …Implementation …Evaluation

Standard of Practice

„

Assessment: Collects comprehensive

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ti

t t th

ti

t’ h

lth

th

data pertinent to the patient’s health or the

situation

…Collect data: on-going process

…Collect data from the family or other healthcare providers

…Prioritize care based on the immediate needs and culture of your patients/families.

„ Assess data using the appropriate tools for hospice care …PPS …PPS …BMI …FAST scale …Psycho-social items …Spiritual needs

„ Identifies patterns and variances

„ Identifies patterns and variances

„ Document assessment

„ Communicate assessment with IDT members and/or consultants

Standard of Practice

„

Diagnosis: Analyze the assessment data

to determine the nursing diagnoses or

issues

„Problems to be addressed:

… with actual or potential responses

„Validate the issues with the patient/family or healthcare provider

healthcare provider

„Consider the age and condition of pt when formulating the nursing diagnoses

„Document and communicate

Standard of Practice

„

Outcomes Identification: Identifies

„

Outcomes Identification: Identifies

expected outcomes for the plan of care.

…Individualized for the patient

…Involve pt/family, other healthcare providers, and IDT members to formulate expected outcomes to improve quality of life

outcomes to improve quality of life

…Benefit/Burden

Patient/family goals for care

Time frame to meet the goals

Assure for continuity of care goals

Assure for continuity of care goals

across all care settings

Modify goals according to patient

condition/circumstances

Document

Communicate

Standard of Practice

„

Planning: Develop a plan of care that

„

Planning: Develop a plan of care that

prescribes strategies and alternatives to

attain expected outcomes

…Individualized care plan based on choice, and appropriateness for the patient’s age, culture

…Strategies may include promotion and

…Strategies may include promotion and

restoration of health and prevention of illness, injury, disease

Standard of Practice

„

Best practice

„

Best practice

„

Economic impact

„

Compliance with rules/regs, standards

„

Communicates with the IDT

Standard of Practice

„

Implementation: Implement the identified

„

Implementation: Implement the identified

plan of care

…Appropriate interventions/treatments specific to the diagnosis

…Care Coordination

…Provides education

…Safety

Standard of Practice

…Facilitates change in plan of care as needed

…Facilitates change in plan of care as needed after consultation with the IDT, family or other health care providers

…Remains compliant with rules/regs

…Documents

Standard of Practice

„

Evaluation: Evaluates progress towards

reaching the expected or desired

outcomes

…Makes changes to the plan of care as indicated

…Collaborates with patient/family, other p y, healthcare providers, IDT

Standards of Professional

Performance

„

Quality of practice: Nurse systematically

„

Quality of practice: Nurse systematically

enhances the quality and effectiveness of

nursing practice.

…Responsible

…Accountable

…Ethical

…Ethical

…Utilizes new knowledge for decision

making/interventions when desired outcomes are not achieved

Standards of Professional

Performance

„

Education: attains knowledge and

„

Education: attains knowledge and

competency that reflects current hospice

and palliative nursing practice

„

Professional Practice Evaluation:

Evaluates one’s own nursing practice in

relation to professional standards and

guidelines, rules/regs

Standards of Professional

Performance

„

Collegiality: Interacts with and contributes

g

y

to the professional development of peers

and colleagues

…Shares knowledge and skills

…Interacts with peers to enhance one’s own professional practice and performance

…Maintains caring and compassionate peer relationships

…Contributes to a supportive and healthy work environment

Standards of Professional

Performance

„

Collaboration: Collaborates with the

„

Collaboration: Collaborates with the

patient, family, IDT, and others

…Communicates the nurse’s role in the provision of care

…Partners with others to effect change

Standards of Professional

Performance

„

Ethics: integrates ethical provisions in all

„

Ethics: integrates ethical provisions in all

areas of practice

„

Research: integrates research findings

into practice

„

Resource Utilization: considers factors

related to safety effectiveness cost and

related to safety, effectiveness, cost, and

impact on practice in the planning and

delivery of nursing service

Standards of Professional

Performance

„

Leadership: provides leadership in the

professional practice setting and the

profession.

Key Components of the RN Case

Manager Role

Case Manager versus

Visit Nurse:

What differentiates the two roles?

What differentiates the two roles?

Case Manager or Visit Nurse?

„

Visit nurse:

„

Visit nurse:

…Assessments

…Treatments

…Interventions

…Collaboration with the Case Manager

Key Components of the RN Case

Manager Role

„

Case Manager: Must coordinate the work

„

Case Manager: Must coordinate the work

of the interdisciplinary team.

…Coordinates each patient’s plan of care as effectively and efficiently as possible.

…Implements care as effectively and efficiently as possiblep

…Evaluates the care provided

…Monitors outcomes of care

Role of the Case Manager

„

Clinical oversight of plan of care including

„

Clinical oversight of plan of care, including

disciplines involved in the patient’s care

…Are the physical, psychosocial, spiritual needs being met?

…Clear understanding of the pt/family goals for d th t f th

Role of the Case Manager

„

Social Worker

…Reviews documentation

…Collaboration to coordinate interventions to achieve goals

…All issues identified and communicated across the IDT.

Role of the Case Manager

„

Spiritual Care/Counselor

„

Spiritual Care/Counselor

„Reviews documentation and/or

collaboration to assure goals don’t conflict

„Awareness of religious rituals and

expectations at time of death

If SCC i i i i h i i l d

„If no SCC is visiting, are the spiritual needs still being assessed?

Role of the Case Manager

„

STNA

„

STNA

…STNA assignment developed with pt, family, and current caregivers

…Supervision every 14 days

…STNA present

…STNA not present „

Volunteer

…Purpose/goals for care

„

Other disciplines, i.e. therapies

Role of the Case Manager

In collaboration with the IDG team the case

In collaboration with the IDG team, the case

manager identifies the need to adjust the

scope and frequency of the discipline’s

visits to achieve goals

************

Role of the Case Manager

„

Clear understanding of the following:

…Terminal diagnosis for each pt.

„Aware of pt’s. health history

„LCD guidelines for the different diagnoses „Assessment identifies the key qualifiers for

the diagnosis and the documentation the diagnosis and the documentation supports the diagnosis

„Determines if the diagnosis is still the

appropriate terminal diagnosis

Role of the Case Manager

„

The Case Manager understands:

…Benefit periods

„90 days „60 days

„Face to face physician encounter

requirements

…Expectations for insurance reimbursement

…Dates for recertification

„Appropriate information presented at IDG meetings for medical director to review

Role of the Case Manager

„ Nurses relay information to the Medical Director C d it b t th tt di h i i d

…Conduit between the attending physician and the medical director

„ Understands the responsibility of the Medical Director’s role of oversight for the medical aspect of the plan of care

C ill l t th M di l

…Case manager will relay to the Medical Director the complete and concise picture of the pt status as it relates to the certification or recertification of a pt.

Role of the Case Manager

„ Management of drugs medical supplies and

„ Management of drugs, medical supplies and DME

…Safety

…Education

…Appropriate use

…Cost: Aware of costs for care „Suppliespp

„Meds

„Interventions „Diagnostics „etc.

Role of the Case Manager

„

Assessment of appropriate level of care

„

Assessment of appropriate level of care

and changes to the plan of care

…Routine

…Continuous Care

…Respite

…GIP

Role of the Case Manager

…Ensures all providers work as a team

…Ensures all providers work as a team

„SNFs „ALFs „Caregivers

„Working towards the same goals „Assures the goals are pt/family drivenAssures the goals are pt/family driven

…Documentation shows evidence of collaboration

Role of the Case Manager

„

Infection control

…Prevention

…Control

…Education

Role of the Case Manager

„

Strong clinical and assessment skills

„

Strong clinical and assessment skills

…“Eyes and ears for the physician”

…Understanding of the disease trajectory of pt

…Assessment of H/P, secondary dx, and co-morbids

…Effectiveness of current medication regime

…Effectiveness of current medication regime

…Communication with physicians

Role of the Case Manager

„

Critical thinking skills

„

Critical thinking skills

…What is needed for palliation of symptoms

…Anticipate needs

…Monitor care from previous interventions

…Who should be involved

„Are symptoms physical emotional or spiritual in „Are symptoms physical, emotional, or spiritual in

nature?

…Solid nursing judgment

Role of the Case Manager

„

Organizational and time management

„

Organizational and time management

skills

…Expectations increased

…Decreased reimbursement

Role of the Case Manager

„

Flexibility

„

Flexibility

…Supportive to the team

„

People Skills

…Collaboration and Conflict resolution

„Families „Facilities „Facilities „Physicians

…Excellent Listening skills

Role of the Case Manager

„

Ability to work independently

„

Ability to work independently

…Collaboratively

„

Integrity/Professionalism

…Need to be able to trust them in the field to be doing what they say they are doing

„

Comfortable with difficult conversations

„

Comfortable with difficult conversations

…Food and fluid decisions, code status, death and dying

Educational Needs

„

Hospice as a philosophy of care

„

Hospice as a philosophy of care

…Must understand and educate on comfort care goals versus curative goals for care

…Assist pts/families in making informed decisions

„

Define Hospice and/or Palliative Care

„

Define Hospice and/or Palliative Care

…Change in mindset from acute care or long term care

Educational Needs

Eligibility

Eligibility

…Evaluating for care

…Reimbursement

„

Regulations

Educational Needs

„

Medicare Hospice Benefit

…What is incl ded in the benefit

…What is included in the benefit

…Compliance

…Face to Face requirements

…Levels of Care

„

Reimbursement

„

Insurance plans

„

Medicaid

Educational Needs

„

Pain and symptom management

„

Pain and symptom management

…Included in the regulations as a patient right

…Must possess solid working knowledge of interventions

„People defer to hospice recommendations

…Equianalgesic dosing

Educational Needs

„

The Hospice Team

„

The Hospice Team

…Understanding of the role for each team member

…Expectations for visits from each team member

S d f f i i

…Scope and frequency of visits

Educational Needs

„

Policy/Procedures

„

Policy/Procedures

…Solid working knowledge

Educational Needs

Supervisory Role

Supervisory Role

Educational Needs

Hospice as a business

Hospice as a business

…Solid working knowledge and understanding of the business aspects of care/costs

„Supplies „DME

„Medications

„Diagnostics and testing, treatments „Mileage

Special Considerations

Id

tif i

d f lif t

k

„

Identifying end of life tasks

…Focus on the “whole” person…

„Symptoms are managed so the emotional and spiritual work of dying can be completed

Wh t EOL t k d t b li h d f

…What EOL tasks need to be accomplished for a peaceful death to occur?

Special Considerations

„

Boundaries

„

Boundaries

…Healthy boundaries maintained

…Appropriate “hand-offs” to the interdisciplinary team

…Enable and empower the family, care-giver or

f ili f h i d f lif d

facility to care for the patient at end of life and in the dying process

Special Considerations

„

Survey Climate

„

Survey Climate

…Need to be survey ready every day

…Increased scrutiny

„ADRs, RACs, CERTs, ZPICs, etc……

„Competency is reflected in the medical record decreasing the potential for denials

decreasing the potential for denials

Differentiators for your hospice!

Competent Case Managers:

Competent Case Managers:

„

Improved outcomes for pt/family

„Goals achieved „Symptoms managed „Quality of life improved

D h i h di i „Death with dignity

„Positive effect for bereavement of family members „Decreased cost to the healthcare industry

Differentiators for your hospice!

„

Positive impact on the hospice industry

„

Positive impact on the hospice industry

…Skilled and competent case managers will find increased respect in the health care community for their expertise in end of life care

„

Positive impact on the hospice

p

p

organization

…“World Class” or “Stellar” hospice care

Differentiators for your hospice!

„

Greater job satisfaction:

„

Greater job satisfaction:

…Case mangers see clearly the impact they have on the patient and family’s quality of life

…Positive effect on recruitment

„

Staff retention

…Greater continuity of care for pts/families

“To laugh often and much; to win the respect of intelligent people and the affection of children; to

f

earn the appreciation of honest critics and to endure the betrayal of false friends. To

appreciate beauty; to find the best in others; to leave the world a bit better whether by a healthy child, a garden patch, or a redeemed social condition; to know that even one life has condition; to know that even one life has

breathed easier because you have lived. This is to have succeeded.” Ralph Waldo Emerson

Q

ti

!

Questions!