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SCHERVIER NURSING CARE CENTER

Palliative Care in Long-Term Care:

Good Practices and Tools for Success

Wadie Utkovic, LCSWSocial Work Supervisor, Schervier

Nursing Care Center, Bronx, NY

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Bon Secours New York:

Schervier Nursing Care Center

364 beds (292 LT and 72 Sub-acute) in the Bronx, NY

Why are we here?

Each year in the U.S., 31% of elders who die, do so in hospitals.

- Expensive and often unnecessary treatments

- Treatments often cause discomfort and distress

- Often surrounded by strangers

- Staff ill-equipped to deal with death

- Little support for the family

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Our Mission

The mission of the Bon Secours Health System is to bring compassion to health care and to be

Good Help to those

in need, especially

those who are poor

and dying.

Looking Back to August 2011

- 15 out of 292 long term residents on palliative care (5%)

- Palliative care committee meeting infrequently

- Focus and priority was not on palliative care

- Undergoing staff changes

- Uncertainty of the meaning of palliative care

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What happened?- Palliative Care was made a system priority in FY12 (Sept ‘11 – Aug ’12)

- Statistics on palliative care were included in monthly dashboard reports

- Administrative focus was on Palliative Care

- Director of Social Work awarded 2 year Leadership Fellowship in Palliative and End-of-Life Care at New York University

- Palliative Care Information Act

- Palliative Care Access Act

Process Changes Made

- Established Regular meetings of the Palliative Care Committee, with new committee chair

- Reviewed and Revised policy and procedure on Palliative Care

- Within this P&P, established each discipline’s role in what they did differently for residents on Palliative Care (nursing, medicine, social work, dietary, recreation, pastoral care, rehabilitation, volunteers…)

- Educated staff on the differences of goals of care

- Educated residents and families of the differences of goals of care (resident and family council meetings)

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Process Changes Made- Began presenting palliative care concepts and philosophy at

new employee orientation

- Listed all residents on palliative care on daily census report

- Included discussions on palliative care in daily morning report on residents who were failing (weight loss, pneumonia, repeat hospitalizations)

- Funeral planning and burial guide

- Set annual performance goals with palliative care measures

- Unit tracking of advance directives by social work

Advance Directives TrackingMonth 2North 2South 3North 3South 4North 4South 5North 5South

HCP TF DNR HCP TF DNR HCP TF DNR HCP TF DNR HCP TF DNR HCP TF DNR HCP TF DNR HCP TF DNR

Sept 85% 1.00 61% 78% 2.00 68% 48% 2.00 70% 75% 5.00 55% 70% 2.00 70% 65% 5.00 63% 42% 2.00 70% 64% 4.00 56%

Oct 88% 1.00 67% 83% 2.00 65% 52% 1.00 64% 80% 5.00 58% 70% 2.00 70% 69% 4.00 60% 47% 2.00 78% 60% 4.00 58%

Nov 88% 1.00 67% 88% 2.00 68% 51% 1.00 70% 80% 4.00 58% 70% 2.00 73% 79% 4.00 69% 47% 2.00 73% 62% 3.00 58%

Dec 88% 1.00 67% 88% 3.00 68% 58% 1.00 76% 83% 3.00 60% 70% 3.00 73% 75% 4.00 72% 52% 2.00 70% 56% 3.00 74%

Jan 88% 1.00 67% 88% 3.00 68% 55% 1.00 76% 89% 3.00 61% 67% 2.00 73% 74% 4.00 74% 56% 2.00 70% 55% 2.00 70%

Feb 84% 1.00 55% 85% 2.00 60% 55% 1.00 78% 89% 3.00 61% 67% 2.00 70% 74% 3.00 77% 45% 2.00 70% 55% 2.00 73%

Mar 82% 1.00 56% 88% 2.00 60% 51% 1.00 79% 88% 2.00 65% 70% 1.00 76% 74% 4.00 77% 42% 2.00 73% 55% 2.00 75%

Apr 85% 1.00 55% 88% 2.00 60% 50% 1.00 81% 85% 2.00 60% 70% 1.00 82% 77% 4.00 85% 46% 2.00 70% 55% 2.00 75%

May 82% 1.00 58% 88% 2.00 63% 50% 1.00 84% 85% 1.00 65% 70% 1.00 85% 74% 4.00 85% 45% 2.00 70% 55% 2.00 75%

Jun 85% 1.00 57% 88% 2.00 61% 52% 0.00 81% 83% 1.00 64% 70% 1.00 85% 74% 4.00 85% 47% 2.00 67% 58% 2.00 71%

Jul 91% 1.00 55% 90% 2.00 59% 48% 0.00 88% 80% 1.00 65% 64% 1.00 82% 72% 4.00 85% 42% 1.00 70% 53% 3.00 75%

Aug 91% 1.00 56% 90% 2.00 59% 48% 1.00 85% 85% 1.00 67% 64% 1.00 82% 72% 4.00 85% 43% 1.00 70% 52% 3.00 78%

Avg YTD

86% 60% 87% 63% 51% 78% 84% 62% 69% 77% 73% 76% 46% 71% 57% 70%

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Program Components

- Use of Palliative Care Order Sheet to help guideClinical Staff interventions

Allows staff to take a fresh lookat a resident, and build a newplan of care (vs. editing an existing plan of care)

Program Components

- Identification of direct palliative care admissions on admit sheet

- Care plan meetings asap with resident and family

- Daily visits by pastoral care staff

- Private room whenever possible

- Flexibility in meeting family “special requests”

- Accommodations for family membersto stay overnight

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Program Components

- Post-death condolence card from all unit staff

- Sharing of resident wake/shiva & funeral arrangements with staff, with at least one staff member attending

- Bi-annual memorial service with slideshow

Results (Sept ‘11 to Aug ‘12)

Residents on palliative care went from 15 (5%) to 72 (25%)

Residents with HCPs went from 65% to 69% (6% increase)

Residents with DNRs went from 64% to 73% (14% increase)

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Results (Sept ‘11 to Aug ‘12)

Residents with feeding tubes went from 24 to 14

(42% decrease)

WOW!

“About one third of U.S. nursing home residents with advanced cognitive impairment have feeding tubes. In this

setting, such tubes can cause discomfort and have no demonstrable health benefits"

(JAMA, July 2, 2009, pp. 73-80).

Results (Sept ‘11 to Aug ‘12)

30 Day re-hospitalization rate went from 17.4% to 15.2%

(13% decrease)

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Increased Partnerships

- Columbia Presbyterian Medical Center

- NYU Medical Center

- Calvary Hospital

- Montefiore Hospital

- NCBH/Jacobi Hospital

- Mt. Sinai Hospital

- Riverdale Neighborhood House

Direct Palliative Care Admissions

Since outreach began in January 2012, we have had 52 direct palliative care admissions from hospitals

Performance improvement project

underway to analyze results to

improve outcomes

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Other Opportunities

Obtained $103,000 grant from the Fan Fox & Leslie R Samuels Foundation for a Palliative Care Transitions Coach – started in February, 2013 and has brought almost $500,000.00 in revenue to the facility

Social Work intern program with MSW students from NYU to provide further support to residents on palliative care and their families

Other Opportunities

Palliative care is an integral part of our daily clinical discussions and strategic planning.

Clinical Leadership Vision Statement:“Our vision is to be a world class, faith based organization; a leader in providing exceptional rehabilitative, palliative, dementia and long-term care. We value clinical excellence, research, and evidence-based practice, achieved through collaboration and innovation, to enrich the quality of life of those we serve”.

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Role of Hospice in Palliative Care

- 1:1 time with home health aide

- Help with symptom management

- Additional family support

- 1 year bereavement support

Case Study

Joan- 85 year old woman, admitted to the facility in 2004

- On admission, post CVA, dysphagia with a feeding tube

- After rehab, could eat normally and feeding tube was removed

- Very active within the nursing home, especially involved in daily mass, and was resident council president

- Used to be a Sears catalogue model, loved wearing red lipstick

- Increased falls, health was deteriorating, wanted her independence

- Early September, suffered another CVA, rendering her incapable of speech, bedbound and unable to swallow

- Daughter (health care proxy) initially wanted feeding tube placed

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Take Aways

1) Include care of the dying in your

mission statement, or at least in your vision statement

2) Ensure you have at least 2 champions: one with decision-making power, and one with the passion for implementation

3) Set goals you want to achieve 4) If you measure it – it will change

Take Aways5) Take a Fresh Look – create a new plan, don’t revise an old one

6) Incorporate discussions on palliative care on a DAILY basis

7) Communicate Results

8) Have a WOW slide

9) Forge good partnerships

10) You can’t win them all – but you can empower, guide and support

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Thank you!

Questions?

Wadie_Utkovic@bshsi.org