Interdisciplinary pathway improves teamwork, care

Pathways increase staff satisfaction

Hospice Care Plus of Berea, KY, switched to a pathway model for patient care in the mid-1990s as way to improve care for patients and their families. What they’ve found in the decade since beginning the process of changing their care model is that it also has improved teamwork, communication, and staff satisfaction.

"We wanted a stronger interdisciplinary approach," says Gail McGillis, RN, MSN, chief executive officer of Hospice Care Plus.

After talking with staff and outlining what each discipline did with patients, they found that with rare exceptions, all of the disciplines had overlaps in the specific care they provided, so it made more sense to strengthen the interdisciplinary approach, McGillis says. "We decided the old system didn’t match the hospice philosophy, and we needed a different type of documentation system and other changes," McGillis says.

After a lengthy search for a good fit, hospice administrators decided to create a pathway model, which didn’t completely evolve to its present form until a few years ago, McGillis says. "We wanted to change it from handwritten to computerized, so when we were looking for a computer system, we wanted something that was the way we needed the pathways to be," McGillis says. The result is a detailed pathway that divides patient care into five phases, from preadmission to bereavement.

Staff satisfaction improved from 70% to 90% after the pathway was implemented, McGillis says.

While the time spent doing documentation is about the same, it is easier and more efficient now, she says. For instance, when a new nurse or staff member enters a patient’s home for the first time, they used to have to read seven or eight notes to learn what was going on with that patient, and now they can read one note for a complete update on the patient, McGillis explains.

Although the pathway is extensive, the staff quickly memorized it, says Peggy Patrick, MRE, chaplain discipline leader. "You go through the categories to make sure you don’t miss anything," Patrick says. "We carry the philosophy with us in our heads and hearts."

The expectations, listed as bullet points for each phase, were developed with the staff’s expertise and knowledge, McGillis says. "We use their expertise to say what is normal with what’s happening to patients at any point in time," McGillis explains. "The pathway describes what the outcome is that the patient and family typically need at that point in time, and it’s driven by the expertise of people who had done hospice work for 10 years or more."

The documentation system also fits the patients’ and families’ needs, McGillis says.

From a nursing perspective, it is a more intuitive documentation system, says Nancy Isaacs, RN, primary nurse for the hospice. "I’ve been a nurse for 36 years and have worked in hospital long-term care settings and used several different models of documentation," Isaacs says. "And this is by far the most sensible and logical way to look at patient care, and I’d never choose to go back to any other model after using this one."

The biggest difference between the care plans used in hospice and plans used in the hospital is that hospital plans were based on diagnosis, Isaacs says. "For this pathway, all we look at is the terminally ill patient, and it doesn’t matter what the diagnosis is," she adds.

By the time patients have been diagnosed as having less than six months to live, they all have the same kinds of basic needs, Isaacs says. "So we plan their care according to whatever their needs are," she says. For example, in the first two phases, hospice staff expect patients to be alert and oriented, while in the later phases, the staff work toward keeping the patient as comfortable as possible and minimizing the patient’s confusion, Isaacs says.

"The pathway is more about what we need to do for the patient and family to make them comfortable," McGillis says. "Our care plan has been modified so it changes as a patient gets closer to death, and that’s why it’s in five phases, which all patients go through, and there are different outcomes for the patient for each phase."

The pathway reinforces a concept of teamwork, and this strengthens interdisciplinary care within hospice care, Patrick notes. "Now everyone is working off the same sheet of music and talking about the same issues rather than everybody having their own issues," Patrick says. "Spirituality blends into social work, but the chaplain at the same time might be talking about comfort and how that impacts the patient."

The pathway model uses the term "expected patient outcomes" (EPOs), which are the ideal of what staff hope to have the patient and family achieve for a particular phase, McGillis says. For example, in phase II, the EPO for nutrition is to make certain the patient is comfortable with food choices and that the family knows what to expect, McGillis says.

By phase IV, which is when the patient is expected to live for less than two weeks, the patient’s nutritional EPO is to be comfortable but probably not eating anymore, and the family’s EPO is to be comfortable and accepting of the situation, McGillis adds. "Most families still are very concerned with having patients eat because they’re used to feeding people when they’re sick and trying to make them well again," Patrick explains. "So we do a lot of teaching about what’s normal in this area as people get closer to death."

Training staff is one of the more difficult aspects of using the pathway, because nurses and others who come from a hospital setting are accustomed to focusing on treatment goals rather than on a hospice care pathway EPO, Isaacs says. "The first thing I usually do with a new employee is start off with the five phases and tell them what they are and say, When we see people, here’s which phase they’re in,’" Isaacs says. "Then we look at the EPOs and the patient and see how we’re doing with them."

When the hospice first switched to care pathways, it was a battle to obtain buy-in from the staff, many of whom had worked for the organization for years, McGillis recalls. "But once they did switch to the pathways, they would never go back," McGillis says. "The pathways make people think more critically about what they’re doing and why they’re doing it for their patients and families."

The pathways also have taught the staff how each team member brings his or her own values to each of those outcomes and how the pathway creates a holistic model, McGillis says.

Pathways summarized for physicians

Although the staff now are fully on board with using the pathways, which typically are five pages long, physicians are not, so they’re given one sheet of paper that summarizes care for a patient at one point in time, McGillis notes. "We add a narrative summary to the report for physicians," McGillis says. "That’s what they want to look at, since the care plan is too long and arduous for them to go through and the pathway is too long."

Twice each month, the hospice staff meet with the medical director to go over all the EPOs that have been covered in the past two weeks, Patrick says.

For staff purposes, the notes they write electronically will update the pathway, making the pathway part of daily documentation, McGillis says. "Every note has a pathway incorporated into it, and they say whether a patient is meeting that outcome or not and why not," McGillis explains.

"If a patient is not meeting those outcomes, then the team plans different approaches to help them meet those outcomes, and that’s called a variance," Patrick says.

From a nursing perspective, communication has improved since the pathways were incorporated, Isaacs says. "The team has to agree and all decide together to move patients from one phase to the next phase," Isaacs says. "We have a team meeting every week where we talk about that."