CMs coordinate care for patient at end of life
CMs coordinate care for patient at end of life
Hospice team supports families, each other
A team approach to hospice care helps members of the interdisciplinary team provide support for patients and each other at HealthEast Hospice Care, based at St. Joseph’s Hospital in St. Paul, MN. The hospital is part of the HealthEast Care System, also in St. Paul.
Nurse case managers lead the program’s interdisciplinary hospice teams, which include social workers, who provide family support and counseling, bereavement counselors who work with the family for up to a year following the death, chaplains who coordinate spiritual care, a medical director who works exclusively with the hospice program, and the patient’s own primary care physician.
The team also includes the volunteer coordinator who recruits, orients, and trains volunteers from the community. The role of the volunteer is to provide administrative support and supportive care for the patient.
Home health aides, working closely with the RN case manager, provide personal care for the patient. "Everyone on the team works together to support each other," says Beth Spottiswoode, RN, BSN, director of hospice care for HealthEast Hospital System.
Team conferences are a cornerstone of the program that helps facilitate patient care and gives team members a chance to discuss any issues or concerns. The interdisciplinary team meets twice a week with the medical director and reviews each case, compiling a report for the primary care physician.
During the conferences, each member gives updates on his or her patients and asks for suggestions or support from the other team members. For instance, if one person has just had an upsetting experience with a stressed-out family, he or she brings it up with the team and they discuss it.
"It takes a special person to work with patients in a hospice situation. The team works closely together, and they support each other when a team member has had a difficult time," Spottiswoode says.
The hospital-based hospice program offers a combination of hospital and home-based hospice care. Patients may be admitted to designated hospice beds in the hospital or assigned to The Pillars Hospice Home, an eight-bed residential facility in the community, but the majority of care takes place in the patient’s or a family member’s home, assisted-living centers, and nursing homes.
"The whole goal around hospice is to support and manage a good dying process for individuals with terminal illnesses and to have healthy family survivors following the death," Spottiswoode notes.
Case managers and social workers are paired and care for the same patients in the same geographic area.
The nurse case managers who travel to the patients’ homes have a caseload of eight to 12 people. Those who see patients in long-term care facilities where they may have several patients in one location, can handle as many as 15 or 16 patients at a time.
The nurse case managers and social workers work as a team, sometimes making joint visits and staying in constant contact by cell phone and beeper.
When the case is first referred for hospice care, the nurse and social worker visit together.
"We don’t meet with anyone alone. We make sure the patient has a supportive person with them when we give them information about the program," Spottiswoode adds.
How the program works
Here’s how the program works: First, the program’s admissions nurse and social worker visit the patient to admit him or her into the program.
For a patient to be admitted to hospice care, the physician has to medically certify that the patient’s disease is at an end stage. The patient or his or her authorized representative has to sign a consent form indicating that the patient is willing to participate in a hospice program.
HealthEast Hospice Care also requires written consent from the primary caregiver, accepting responsibility to be the spokesperson for the patient. Once someone signs onto the program, the program registers them with the medical examiner’s office in their county as an expected death, to occur at home, saving the family the trauma of having to have the police come out when the patient dies.
When a patient is admitted to hospice care, the RN case manager visits the family and makes a physical assessment of the patient, his or her condition and needs, and begins to develop and coordinate the plan of care.
Working with the medical director and the patient’s primary care physician, the case manager comes up with a detailed plan of care that will help family members manage advanced illness symptoms at home. The plan of care includes the frequency of visits by members of the interdisciplinary team, based on the patient’s needs, and the ability of family members to care for him or her.
The case manager assesses the patient’s need for equipment, orders it, and makes sure it is delivered. The program’s standard equipment includes an electric hospital bed, wheelchair, walker, commode, and oxygen concentrator.
"We do whatever we have to do to manage the symptoms. Not everybody has the same needs," Spottiswoode says.
When the plan of care has been developed, the case manager and social worker visit the family and discuss the plan with them.
Two weeks to a month later, the team sets up a family care conference, led by the social worker, where the family can ask questions, discuss their concerns, mention any needs that aren’t being met, and receive support.
The case manager visits the patients regularly, usually two to three times a week, assessing the condition and providing hands-on care to help manage any problems that occur, such as constipation, a frequent side effect of pain medication. The program has routine standing orders for medications to manage symptoms if the need arises, eliminating the need to call the physician for approval when something comes up.
"We try to manage the symptoms with a low-tech approach. As you increase technology in the home, you increase the need for professional visits. We try to be respectful of the family and not make unnecessary visits," Spottiswoode notes.
For instance, the case manager works with the pharmacist to get concentrated medications or patches that will provide pain medicine topically, to avoid the use of IV drugs.
"We work to keep the family system intact so that they are able to care for their loved one with our support, rather than going in and assuming all the care needs because we think the family can’t manage it," she says.
If the family is unwilling or unable to provide personal care for the patient, such as bathing and changing the bed linens, the case manager schedules home health aides to visit several times a week.
The home health aides stay in close touch with the case managers, alerting them if the patient’s condition has changed. The case manager then visits the home again and assesses the patient to determine if he or she needs a change in treatment or to be moved to a different level of care.
The case manager works with the hospice program’s medical director and primary care physician when the patient’s symptoms become difficult to manage or there is a change in condition.
They collaborate on changes in the plan of care, including moving the patient to another location. "It is obligatory that the majority of deaths do occur at home. That’s the whole intent of the hospice movement," Spottiswoode says.
Under the Medicare requirements, HealthEast Hospice Care provides four levels of care: routine home care, including home visits by the multidisciplinary team, medications and special equipment; general inpatient level for care when the patient’s care can’t be managed at home; respite care of up to five-day stays to give the primary caregiver a break; and continuous care, providing round-the-clock nursing care, usually for a duration of 10 days or less.
The case manager is responsible for changing the levels of care when it’s appropriate and working with the rest of the team to coordinate care and communicate the needs of the visit.
All members of the interdisciplinary team are in the office at least once a day. The case managers either come in each morning and go home directly after they finish seeing their patients, or they start from home and come to the hospital to take care of documentation and other paperwork at the end of the day.
They stay in touch by cell phones and beepers. The hospital is in the process of computerizing the program, providing laptops for case managers, social workers, and other team members who provide direct patient care.
Although Medicare will pay for hospice care for up to six months, many referrals come later, says Spottiswoode. The program’s average length of stay is 50 days, up from seven days or less when she started working in hospice care in 1991.
"Hospice has stood the test of time. It’s now recognized by Medicare and health plans as a cost-effective care plan," she adds.A team approach to hospice care helps members of the interdisciplinary team provide support for patients and each other at HealthEast Hospice Care, based at St. Josephs Hospital in St. Paul, MN. The hospital is part of the HealthEast Care System, also in St. Paul.
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