Hospice patient handbook increases satisfaction

Patients, staff use book with each visit

A Florida hospice has created an education program that helps it handle its rapid growth while improving patient and family satisfaction. Each year, Covenant Hospice of Pensacola, FL, gives away more than 1,000 patient education handbooks that serve as a comprehensive guide to hospice for both families and hospice staff.

The hospice has given away about 5,000 handbooks since the education tool was created several years ago, says Julie Patton, LCSW, curriculum development manager for the hospice, which has more than 700 employees.

Covenant Hospice won an award of excellence in education last year for its patient and family education program. The award was sponsored by the National Council of Hospice and Palliative Professionals and presented by the National Hospice and Palliative Care Organization of Alexandria, VA.

Also, Covenant Hospice’s family satisfaction with education increased from around the 40th percentile in July 2001 to the 70th percentile in December 2003 as a result of using the education handbook. The measure for family satisfaction in receiving adequate help in combating stress and anxiety increased from the 50th percentile in 2001 to about the 80th percentile in 2003, Patton says. "And we had 97% of caregivers [in a recent survey] say that hospice had increased their confidence in caring for their loved one as death approached," she adds.

In 2001, when Covenant Hospice’s staff were preparing for re-accreditation by the Joint Commission on Accreditation of Healthcare Organizations of Oakbrook Terrace, IL, they decided their patient education program wasn’t working as well as they wanted it to, Patton says. "There were a lot of different teaching sheets, and to make it successful, a nurse needed to have the right sheets in the home at the right time," she says.

Boosting education, improving care plans

The idea for an education handbook was a melding of the patient and family education goals with the hospice’s latest project of improving the care plan process, Patton explains. "In talking about it, we felt the two would complement one another."

When hospice managers began to examine the current care planning process, they realized it involved too much writing and too little interaction with patients, so they decided to reverse those trends, says Dee Leslie, RN, CHPN, director of the Partners in Care Program. Leslie was the one who spearheaded the changes to the care planning process. "Now, when nurses select teaching sheets from the patient education handbook, they also are selecting teaching interventions," she says. "After finishing the teaching sheet, they review the interventions at the bottom to make sure they have covered those teaching interventions."

The handbook is nearly 300 pages long and is fairly inexpensive to produce since the hospice uses its own copying machines, but it does require about 20 volunteers to put it together, Patton says.

While the hospice could have the book published for sale to other hospices, the idea of making a profit from the book doesn’t fit in well with the hospice’s philosophy. "Our philosophy up to this point is that we are all, as hospice providers, contributing to a relatively new body of knowledge," says Liz Stewart, RN, BSN, CHPN, director of internal education.

Patton, Leslie, and Stewart describe how the award-winning handbook was created:

1. A needs assessment was conducted.

"What we found out was we had care plans that had been carried over from a number of different settings and were not terribly hospice-appropriate," Patton says. "So we did an extensive needs assessment."

Hospice staff decided they would need to improve both the care planning process and patient education materials. A committee that included clinicians was formed to develop hospice interventions for problems like pain and nausea or working with the patient and family to comply with around-the-clock dosing, Patton explains.

The result was the development of a care planning process that is simpler than what staff used previously, Patton notes. "In doing care planning, the staff doesn’t have to do a great deal of writing," she says. "They can use a drop-down menu on the computer and select interventions that correspond with teaching sheets."

"What’s unique about the care planning process is it came from the staff up to the management," Leslie says. "It’s a method that makes it easier for hospice staff to do care planning and to do it effectively, without spending a lot of time writing out things."

Also, the care planning process is completely independent of hospice reimbursement and financial concerns, Leslie adds.

2. A separate committee developed the education handbook.

Initially, the hospice’s committee was formed to improve the family education program, but it progressed into a committee to create the patient and family handbook, Patton says. "We were using a file box for teaching sheets, so it became a patient and family handbook," Patton says.

Committee members gathered new information while reviewing existing teaching sheets, and they e-mailed one another with suggestions for changes, Patton says. "I’d write something and send it to someone else to see if they would change anything or if there were things I’d left out or if there was anything that might be offensive," Patton explains. "They’d make comments and e-mail it back to me."

Many different people collaborated on the changes, including Stewart, Leslie, the director of operations, the director of special programs, a social worker, a health and safety officer, and a chaplain, Patton says. "Forty to 50 people contributed to it altogether, including an administrative assistant who prepared dividers and helped with formatting some of the sheets," Patton says.

Hospice staff also came up with ideas to reduce costs in reproducing the handbook. For example, it was begun as a loose-leaf notebook and now is a bound notebook that is printed entirely at the hospice, Patton says. The volume of printing was wearing out the hospice’s copying machines, so the hospice invested in a larger copying machine that also inserts tab dividers, and volunteers assist with the printing and assembling, she adds.

3. Patient education materials were developed with psychosocial issues in mind.

One of the unique features of the handbook is that it reflects the holistic and psychosocial aspects of hospice care, rather than focusing primarily on nursing and medical interventions, Patton says. Many other care plans didn’t reflect the breadth of hospice care, so Patton and others worked to develop many psychosocial teaching sheets. "We feel our program is very broad and reflects the work of everyone on the interdisciplinary team," Patton says. "The teaching sheets identify opportunities for growth at the end of life, and they facilitate growth in a variety of areas, including the spiritual."

4. The patient handbook contains alphabetized sections and teaching sheets.

Stewart recalls that when she was a case manager using the handbook, it was a wonderful tool for hospice families. "When a patient was approaching death and I wanted the family to be aware of the signs and symptoms, or when we had a conversation about hydration, the teaching sheets were there and readily accessible," Stewart says. "The family receives the entire handbook with teaching sheets, and the nurse will identify the sheets to which she refers the family."

Care plans prompt use of teaching sheets

Care planning works closely with the handbook, Leslie notes. "Care planning was integral to the patient and family handbook," she says. "In the electronic care plans, nurses can use a drop-down menu that says Review teaching sheet,’ and there’s a blank space to type in the teaching sheet that’s reviewed."

Also, nurses do not have to repeat the interventions in the documentation because all of these are written in the handbook, Leslie says.

"I found it a very useful tool because, while I might remember some of the interventions, like how to request a volunteer, I may forget to go over what a volunteer can and can’t do," Stewart says. "So I’d open the book to the page on volunteers, and it gave me a prompt of what I needed to say."

Previously, nurses would document teaching with a check-off in the nursing notes of "Teaching accomplished," and they would write on a small line what was taught, she recalls. "Now, because of this tool and electronic care plan, we can better document what teaching has been done and whether it’s a true intervention," Stewart adds.

The teaching sheets are listed alphabetically, and items are cross-referenced in the index, Patton says.

The handbook begins with a mission statement and covers such items as services, on-call system, safety issues, and nursing services before beginning the sections with education and teaching sheets. Also, there are sections devoted to medication, medical equipment, financial and insurance information, and discharge/transfer of hospice patients. "It has an initial section that describes the organization and team," Patton explains. "Then a second section has the teaching sheets, alphabetically arranged, from advance directives to volunteers."

The handbook also covers hurricane preparedness, fire safety in the home, diarrhea and constipation, placement in a nursing facility, and unconventional teaching items, such as opportunities for growth, anxiety, anger and depression, end-of-life care, and a comprehensive description of what a patient might experience, she says.

The book is written at an eighth-grade education level and is in a clear font so it’s easy to read, Patton says.

Patients who are admitted to hospice when they are very close to death are referred to a small section in the book for terminal patients, so they don’t have to worry about reading the entire book if they choose not to, she says.

While the handbook has been a time-consuming and costly project, it has helped improve satisfaction among hospice staff and families of hospice patients, Stewart says. "When the handbooks are put into facilities with hospice families, they’re often left at the facilities, and we’re actually spreading our mission in education by teaching families," Stewart says. "Research shows that, even when one person receives hospice care in a facility, all persons tend to benefit from the education that’s provided."