Improving Palliative Care Management in the Nursing Home Setting: An Interprofessional Approach Nicholas Fredette, RN, DNP Student University of Vermont 2018. Project Advisor: Mary Val Palumbo DNP, APRN It is estimated that roughly 1.4 million adults reside in certified nursing facilities throughout the U.S (KFF, 2017). In 2012 approximately $219.9 billion, or nearly 8% of all U.S. healthcare expenditures were being spent on long-term care services, a number that is projected to reach $346 billion by 2040 (National Health Policy Forum, 2014, SCAN 2013). With the average cost per person of nursing home care hovering around $90,000 annually, the Centers for Medicaid and Medicare Services work to regulate the care provided in these facilities to ensure optimum quality standards and limit costs. Introduction Problem: Current projections indicate that the number of individuals age 65 and older throughout the U.S. will double to nearly 88 million by 2050 Roughly 1.4 million Americans reside in nursing homes (NH) many of whom suffer from chronic life-threatening illness Nearly 25% of those individuals requiring palliative care (PC) services die in nursing facilities Quality of life during the last year of life often decreases in NH residents due to chronic illness Available Knowledge: PC is an approach designed to improve quality of life in patients suffering from chronic life-threatening illness An interprofessional approach to PC can improve quality of life in NH residents NH staff desire increased training and resources pertaining to the provision of PC Efforts to improve PC, aiming at improving the quality of life of residents within the NH setting appears warranted Early PC has been shown to decrease emergency department visits, hospitalizations and hospital deaths Early hospice referrals improve end-of-life (EOL) transitions and decrease frivolous EOL spending Rationale: The American Nurses Association (ANA) Call to Action: Calls for nurses to become more involved in the provision of PC throughout all healthcare settings, including the NH setting Advocates for the use of The National Consensus Project for Quality Palliative Care’s Clinical Practice Guidelines for Quality Palliative Care (2013) Guidelines provide an emphasis towards an interprofessional approach to symptom management and routine assessment of resident needs Contact: Nicholas Fredette Email: nafredet@gmail.com Phone: (802) 558-7595 Methods Purpose & Aims: Establishment of a facility-wide PC program within a NH encompassing skilled-nursing and long-term care services Program to be utilized by nursing staff with the purpose of monitoring resident needs and providing quality care as they progress towards the end of life Program encompasses both a PC protocol and an in-facility, interprofessional PC team Context: Performed within a rural NH in Chittenden County, Vermont designed to manage the complex needs of their residents, many of whom suffer from chronic, life-threatening illness Currently, the facility lacks a specific program aimed at improving the provision of palliative care Administration was eager to examine ways to improve the care of their residents in the context of palliative care Number of key stakeholders including administration, healthcare staff as well as residents and their families Interventions: Needs assessment was performed encompassing: Literature review Retrospective chart audit (n=21) Nursing staff survey Stakeholder interviews Needs assessment drove the creation of the palliative care program Program encompassed: PC protocol Interprofessional PC team Program proposed, accepted by administration and implemented over the course of three months Measures & Analysis Pre- and post-implementation chart audit results Staff survey results/Stakeholder input All quantitative data was analyzed using descriptive statistics Pre-implementation chart results were compared to post-implementation chart results Results Discussion Pre-implementation retrospective chart audit revealed deficiencies in a number of domains Staff survey results: Inconsistency with providing PC Inadequate training and resources Stakeholder buy-in unanimous Pre-Implementation Chart Audit Results: Team met three times, six residents passed away Post-implementation chart audit (n=6) showed improvements in a number of domains Staff involved found team meetings to be useful in managing resident needs High degree of staff turnover throughout implementation Post Implementation Chart Audit Results: Needs assessment a useful tool in the creation of this program Training and resource needs remain desired Staff buy-in was robust Improvements seen in multiple areas including hospice admissions, comfort care orders initiation and out-of-facility transfers Administration desires to continue to use and develop this program Interpretation: Gaps exist in PC despite availability of best practice guidelines Interprofessional team was useful demonstrating feasibility of this program Resources alone may be insufficient as only marginal improvements were seen Improvements seen may have an impact on the healthcare system as a whole Work is needed to improve NH staff retention Limitations: Small sample size, selection bias through chart review Physical/Psychological Aspects: Frequency Pain Screening Q Shift 100% Constipation/Diarrhea Screening Q Shift Incontinence Screening Q Shift Screen for Psychological Symptoms Q Shift 0% Additional Physical Symptom Screening Q Shift Skin Breakdown 76% Efforts Made to Prevent Skin Breakdown Nutritional Assessment by RD 71% PT/OT Referrals 50% Falls within Last 6 Months 48% PT Referral for Those With a Fall 70% Out-of-Facility Transfers with Last 6 Months 29% Social/Cultural Aspects: Social Care Plan in Place 95% Communication Between Staff and Family Cultural Assessment Performed 38% Quarterly Care Conferences Religious/Spiritual Aspects: Religious/Spiritual Assessment Documented Religious Affiliation 33% Documented Chaplain Visits 24% Ethical/Legal Aspects: Durable Power of Attorney for Healthcare in Place DNR/COLST on File End-of-Life Aspects: Comfort Care Orders Initiated End-of-Life Care Plan in Place Hospice Referrals 66% Time Between Last Care Conference and Death 32 days Time Between Comfort Care Orders Initiation and Death 30 days Time Between Hospice Referral and Death 35 days Conclusions A need for more comprehensive PC within the NH setting exists Program is feasible, well-received, and beneficial in improving PC services Staff education and training remains a significant barrier to improving PC within the NH setting Physical/Psychological Aspects: Frequency Pain Screening Q Shift 100% Constipation/Diarrhea Screening Q Shift Incontinence Screening Q Shift Screen for Psychological Symptoms Q Shift 0% Additional Physical Symptom Screening Q Shift Skin Breakdown 83% Efforts Made to Prevent Skin Breakdown Nutritional Assessment by RD PT/OT Referrals 50% Falls within Last 6 Months PT Referral for Those With a Fall 60% Out-of-Facility Transfers with Last 6 Months Social/Cultural Aspects: Social Care Plan in Place Communication Between Staff and Family Cultural Assessment Performed Quarterly Care Conferences Religious/Spiritual Aspects: Religious/Spiritual Assessment Documented Religious Affiliation 33% Documented Chaplain Visits 24% Ethical/Legal Aspects: Durable Power of Attorney for Healthcare in Place DNR/COLST on File End-of-Life Aspects: Comfort Care Orders Initiated End-of-Life Care Plan in Place Hospice Referrals 66% Time Between Last Care Conference and Death 38 days Time Between Comfort Care Orders Initiation and Death 42 days Time Between Hospice Referral and Death 41 days References Call for Action: Nurses Lead and Transform Palliative Care. (2017). [Press release]. Retrieved from http://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/Palliative-Care-Call-for-Action/Draft-PalliativeCare-ProfessionalIssuesPanel-CallforAction.pdf Clinical Practice Guidelines for Quality Palliative Care. (2013). 3rd. Retrieved from https://www.hpna.org/multimedia/NCP_Clinical_Practice_Guidelines_3rd_Edition.pdf Hanson, L. C., Reynolds, K. S., Henderson, M., & Pickard, C. G. (2005). A quality improvement intervention to increase palliative care in nursing homes. Journal of palliative medicine, 8(3), 576-584.