1. Improving Palliative Care Management in the Nursing Home Setting:
An Interprofessional Approach
Nicholas Fredette, RN, DNP Student University of Vermont 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
Phone: (802)
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
Clinical Practice Guidelines for Quality Palliative Care. (2013). 3rd. Retrieved from
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),