Evercare Quality Improvement Awards James Collins, M.D. Julie Hayes, R.N. Randy Muenzner

Faculty Disclosures: Dr. Collins Medical Director, Evercare Pfizer Pharmaceuticals: Speakers Bureau Eisai Pharmaceuticals: Speakers Bureau

Learning Objectives Learning Objectives By the end of the session, participants will be able to: Understand the need for improved End of Life practices in Long Term Care Facilities Identify barriers to End of Life Care Identify end stage disease indicators Understand how the Modified Flacker Mortality tool can be incorporated into existing facility practices

Facility Demographics Elderwood Healthcare at Maplewood Cheektowaga, NY 160 Beds (138 long term/22 subacute) Private Owner

Palliative Care Process Improvement Problem –Recognition of terminal status for residents with chronic illness occurring late in disease process. –Little or no time for families/residents to make informed decisions. –Little or no time for staff to plan or implement quality palliative interventions. –Poor outcomes.

Modified Flacker Mortality Scale Objectives –Provide nurses/physicians with an accurate, objective tool to monitor progression of disease process. –Provide nurses/physicians and families with time to review resident’s status, advanced directives and options for treatment.

End Stage Disease Indicators Resident characteristics assessed on Flacker Mortality Scale: - Functional ability (ADL Score) - Weight Loss - Shortness of Breath -*Swallowing Problems - Sex (Male at higher risk) - CHF - Age * Found in our study to be an early sign of decline.

Project Timeline Study began October 2005 –Funded by Community Health Foundation as a collaborative endeavor with Hospice of WNY and Elderwood Healthcare at Maplewood. Began on one unit with 40 residents –Flacker Tool –Later modified to exclude residents with advance directives for aggressive care. Subsequently identified as the Modified Flacker Tool. Study ended December Completion of Modified Flacker assessments to all long term care residents. January 2008 –Policy was implemented in all Elderwood Senior Care facilities covering over 1300 LTC residents.

QI Planning & Implementation Leadership –Dr. James Collins, Medical Director –Julie Hayes, Assistant Director of Nursing –Informal weekly meetings from 10/05 to 12/06 Facility wide implementation 1/07 –(4) Unit Managers –MDS Coordinators –30 minutes weekly per nurse manager Communication –Informal introduction to interdisciplinary staff over a period of time.

Modified Flacker Assessment How was study conducted? - Formatted Modified Flacker tool into User Defined Assessment Software. Issues encountered & how they were overcome - Staff resistant to change. Residents identified by the tool didn’t look like the type of End of Life Resident with whom staff were familiar.

Tools Used to Affect Change Tools used –Information obtained from last MDS completed. –Assessment schedule follows MDS cycle. Tools created –Modified Flacker Form

Facility Expenses No significant expenses incurred. After initial education and implementation individual nursing time to complete weekly assessments is approximately 15 minutes. No additional staff needed.

Outcomes Resident Outcomes –Facilitates residents to prioritize needs and wishes. –Advanced directives established. –Resident & family directed plans of care. –Residents & family emotionally prepared. Regulatory Outcomes –Care plans are accurately prioritized.

Outcomes Improved Quality of Service –Priority is determined by the resident’s preferences with proper education of possible outcomes. –More effective Pain Management. –Proactive Advance Care Planning eliminates futile and inappropriate treatments. –Spiritual and Emotional needs of both resident and families are identified and addressed by the interdisciplinary team including the Chaplain.

Outcomes Enhance Staff Performance –Early identification of the terminally ill resident enables staff to gain more insight into the special needs of the resident and family. –Improved quality of life at the end of life has enhanced job satisfaction. Effect on Staff’s “every day” routine work –Created a culture within the building to allow for all involved to be comfortable with the dying process.

Outcomes Improved organization & management structure & systems –Modified Flacker Tool is completed at the same time an MDS is completed. Staff member experiences no additional work load. –Clear and timely approach to establishing a Palliative Plan of Care. –When implementing you are only establishing a measurement tool to identify when a Palliative Plan of Care should be activated. –No change in current Palliative Plan of Care nor staffing needs.

Outcomes Financial Outcomes –Revenue neutral for the facility. –Cost savings to the health care industry by reduction in unwanted hospitalizations.

Closing Thoughts What is the feasibility that this project could be implemented at other facilities? –Feasibility is simple. Has been implemented in 9 more facilities. Lessons Learned –How easily culture change occurred when this process was implemented. There was “buy in” from staff, residents and families. Helpful Tips/Insights –One individual can impact an entire facility when they bring forth an idea whose time is come. Any Questions?