National Hospice and Palliative Care Organization’s Palliative Care Resource Series Palliative Indicators in Long Term Care Written by: Brian W. Jones, DHSc, CHPCA

Current Situation Approximately 1.7 million Americans reside in long term care facilities. Annually, 25% of all deaths occur in a nursing home setting. Many nursing home patients are totally dependent or need extensive help for their activities of daily living. Up to 80% of nursing home patients could benefit from palliative care.

Unmet Needs Daily episodes of pain ineffectively managed. Pain is prevalent in 49% to 83% of patients. Pain medication often prescribed “as needed” and not given routinely. Pain is difficult to assess in patients who often have cognitive impairments and multiple comorbidities.

Unmet Needs High staff turnover can lead to inadequate and inconsistent education on pain assessment/management. Scant attention is often given to advance care planning and decision making at end of life. this can lead to unnecessary treatments and prolonged dying for nursing home patients.

Palliative Care Can Help Recent study of 1500 nursing home patients some with PC and some without PC Journal of American Geriatrics Society (Miller,Lima, Interactor, Martin, Bull and Hanson, 2016) PC Consult 8-30 days before death No PC Consult 8-30 days before death PC Consult 61-180 days before death No PC Consult 61-180 days before death Hospitalization Rates 11.7% 22% 6.9% 22.9%

Palliative Care Can Help Hospice, which is downstream palliative care, when initiated in nursing homes can effectively reduce hospitalizations even for non-hospice patients. For every 10% increase in hospice care in nursing homes there is a reduced hospitalization risk in 5.1% of non-hospice patients and 4.8% of hospice`patients.

Palliative Care Can Help Reduced hospitalizations of nursing home patients is an indication that more patients are being managed effectively (symptoms, pain, etc.) in their existing setting.

Identifying Appropriate Patients Nursing homes have lagged behind other health care entities in transitioning to electronic medical records (EMR). EMRs assist in providing algorithms which may indicate the need for palliative care. Paper documentation currently poses a challenge in identifying appropriate patients for palliative care.

Identifying Appropriate Patients: Palliative Performance Scale PPS is a well-known tool in hospice to help ensure eligibility for admission and continued service. One nursing home utilized the PPS in conjunction with their MDS assessment and patients who scored 30% or less automatically received a goals of care discussion between staff, patient, and family.

Identifying Appropriate Patients: Four-Fold Combination “Would I be surprised if this patient does not live beyond a year’s time frame?” Did this patient, if hospitalized, receive a palliative inpatient consultation? Has this patient had two or more hospitalizations within the last 6 months? Are there any documented advance directives or goals of care discussions?

Identifying Appropriate Patients: Edmonton Symptom Scale

Identifying Appropriate Patients: Flacker Mortality Scale Score Probability of Dying in One year 0-2 7% 3-6 19% 7-10 50% 11+ 86%

Identifying Appropriate Patients: RAI-PC The Resident Assessment Instrument for Palliative Care (RAI-PC) is a standardized comprehensive tool to help identify patients who would benefit from palliative care.

Potential Strategies Meet with the MDS coordinator, DON, and/or administrator to identify gaps, needs and ways to collaborate. Share peer reviewed literature on palliative care in nursing homes. Examine hospital readmission patterns among nursing home patients Facility will need to understand ‘what’s in it for them?’

Potential Strategies Design a nursing home palliative care team Examine scope, quality, metrics, volume forecasting, financials and return on investment. Pilot in a small facility that is part of a larger chain or two units in a larger nursing home. Data share.

Potential Strategies Decide which indicators will be used in collaboration. Assess results monthly, quarterly, to ensure goals are being met. Expand services.

Conclusion The ultimate goal is to move palliative care further upstream in nursing homes to provide effective pain and symptom management and overall holistic care for patients.