Presentation on theme: "The National Quality Forum’s Framework for Hospice and Palliative Care"— Presentation transcript:
1The National Quality Forum’s Framework for Hospice and Palliative Care
2How did the NQF Framework project start? Consortium of four key national palliative care organizations formed the National Consensus Project in 2001:American Academy of Hospice and Palliative MedicineCenter to Advance Palliative CareHospice and Palliative Nurses AssociationNational Hospice and Palliative Care Organization
3National Consensus Project Mission To create a set of voluntary clinical practice guidelines to guide the growth and expansion of palliative care in the United States
4Types of PatientsCongenital injuries or conditionsAcute, serious and life-threatening illnessesProgressive chronic conditionsChronic and life-limiting injuries from accidents or other forms of traumaSeriously and terminally ill patients
5Models of Palliative Care Delivery Consultation service teamDedicated inpatient unitCombined consultative service team and inpatient unit (hospital and nursing home)Combined hospice program and palliative care programHospital or private practice based outpatient clinicHospice based palliative care at homeHospice based consultation in outpatient settings
6NQF Framework Eight Domains Structure and Process of CarePhysical Aspects of CarePsychological and Psychiatric Aspects of CareSocial Aspects of CareSpiritual, Religious and Existential Aspects of CareCultural Aspects of CareCare of the Imminently Dying PatientEthical and Legal Aspects of Care
7Domain 1: Structure and Process of Care Comprehensive interdisciplinary assessment of patient and familyAddresses identified and expressed needs of patient and familyInterdisciplinary team consistent with plan of careEducation and trainingEmotional impact of workTeam has relationship with hospicesPhysical environment meets needs of patient and family
8Domain 2: Physical Aspects of Care Pain, other symptoms and treatment side effects are managed using best practicesTeam documents and communicates treatment alternatives, permitting patient/family to make informed choicesFamily is educated and supported to provide safe/appropriate comfort measures to patient
9Domain 3: Psychological and Psychiatric Aspects of Care Psychological and psychiatric issues are assessed and managedTeam employs pharmacologic, nonpharmacologic and complementary therapies as appropriateGrief and bereavement program is available to patients and families
10Domain 4: Social Aspects of Care Interdisciplinary social assessmentCare plan developedReferral to appropriate services
11Domain 5: Spiritual, Religious and Existential Aspects of Care Assesses and addresses spiritual concernsRecognizes and respects religious beliefs – provides religious supportMakes connections with community and spiritual/religious groups or individuals as desired by patient/family
12Domain 6: Cultural Aspects of Care Assesses and aims to meet the culture-specific needs of patients and familiesRespects and accommodates range of language, dietary, habitual and ritual practices of patients and familiesTeam has access to/uses translation resourcesRecruitment and hiring practices reflect cultural diversity of community
13Domain 7: The Imminently Dying Patient Signs and symptoms of impending death are recognized and communicatedAs patients decline, team introduces or re-introduces hospiceSigns/symptoms of approaching death are developmentally-, age- and culturally-appropriate
14Domain 8: Ethical and Legal Aspects of Care Patient’s goals, preferences and choices are respected and form basis for plan of careTeam is aware of and addresses complex ethical issuesTeam is knowledgeable about relevant federal and state statutes and regulations
15Palliative Care Guidelines National Consensus Project Guidelines for Quality Palliative Care published in April 2004Request to NQF to review and endorse the Guidelines
16Framework for Palliative and Hospice Care Review Committee appointed by NQFCommittee reviewed NCP GuidelinesWrote chapter on preferred practicesWrote chapter on research needs of the fieldEndorsed by NQF Board of DirectorsPublished January, 2007
17Definition of Palliative Care Palliative care means patient and family centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social and spiritual needs and to facilitate patient autonomy, access to information and choice.-CMS definition in proposed Medicare Hospice COPs-Adopted by NQF in the Framework document
18NQF Preferred Practices Chapter 2 in Framework38 preferred practicesEvidence-based – not just expert opinionApply to both hospice and palliative care
19Characteristics of Preferred Practices For each domainHoped-for outcomesSet goals for future performance measures
20DOMAIN 1.1. GENERAL STRUCTURE OF CARE PREFERRED PRACTICE 1Provide palliative and hospice care by an interdisciplinary team of skilled palliative care professionals, including, for example, physicians, nurses, social workers, pharmacists, spiritual care counselors, and others who collaborate with primary healthcare professional(s).PREFERRED PRACTICE 2Provide access to palliative and hospice care that is responsive to the patient and family 24 hours a day, 7 days a week.
21DOMAIN 1.1. GENERAL STRUCTURE OF CARE PREFERRED PRACTICE 3Provide continuing education to all healthcare professionals on the domains of palliative care and hospice care.PREFERRED PRACTICE 4Provide adequate training and clinical support to assure that professional staff are confident in their ability to provide palliative care for patients.
22DOMAIN 1.1. GENERAL STRUCTURE OF CARE PREFERRED PRACTICE 5Hospice care and specialized palliative care professionals should be appropriately trained, credentialed, and/or certified in their area of expertise.
23DOMAIN 1.2. GENERAL PROCESSES OF CARE PREFERRED PRACTICE 6Formulate, utilize and regularly review a timely care plan based on a comprehensive interdisciplinary assessment of the values, preferences, goals and needs of the patient and family and, to the extent that existing privacy laws permit, ensure that the plan is broadly disseminated, both internally and externally, to all professionals involved in the patient’s care.PREFERRED PRACTICE 7Ensure that on transfer between healthcare settings, there is timely and thorough communication of the patient’s goals, preferences, values and clinical information so that continuity of care and seamless follow-up are assured.
24DOMAIN 1.2. GENERAL PROCESSES OF CARE PREFERRED PRACTICE 8Healthcare professionals should present hospice as an option to all patients and families when death within a year would not be surprising, and reintroduce the hospice option as the patient declines.PREFERRED PRACTICE 9Patients and caregivers should be asked by palliative and hospice care programs to assess physicians’/healthcare professionals’ ability to discuss hospice as an option.
25DOMAIN 1.2. GENERAL PROCESSES OF CARE PREFERRED PRACTICE 10Enable patients to make informed decisions about their care by educating them on the process of their disease, prognosis, and the benefits and burdens of potential interventions.PREFERRED PRACTICE 11Provide education and support to families and unlicensed caregivers based on the patient’s individualized care plan to assure safe and appropriate care for the patient.
26DOMAIN 2. PHYSICAL ASPECTS OF CARE PREFERRED PRACTICE 12Measure and document pain, dyspnea, constipation, and other symptoms using available standardized scales.PREFERRED PRACTICE 13Assess and manage symptoms and side effects in a timely, safe, and effective manner to a level acceptable to the patient and family.
27DOMAIN 3. PSYCHOLOGICAL AND PSYCHIATRIC ASPECTS OF CARE PREFERRED PRACTICE 14Measure and document anxiety, depression, delirium, behavioral disturbances, and other common psychological symptoms using available standardized scales.PREFERRED PRACTICE 15Manage anxiety, depression, delirium, behavioral disturbances, and other common psychological symptoms in a timely, safe, and effective manner to a level acceptable to the patient and family.
28DOMAIN 3. PSYCHOLOGICAL AND PSYCHIATRIC ASPECTS OF CARE PREFERRED PRACTICE 16Assess and manage psychological reactions of patients and families to address emotional and functional impairment and loss, (including stress, anticipatory grief and coping), in a regular ongoing fashion.PREFERRED PRACTICE 17Develop and offer a grief and bereavement care plan to provide services to patients and families prior to and for at least 13 months after the death of the patient.
29DOMAIN 4. SOCIAL ASPECTS OF CARE PREFERRED PRACTICE 18Conduct regular patient and family care conferences with physicians and other appropriate members of the interdisciplinary team to provide information, discuss goals of care, disease prognosis, and advanced care planning, and offer support.PREFERRED PRACTICE 19Develop and implement a comprehensive social care plan which addresses the social, practical and legal needs of the patient and caregivers, including but not limited to: relationships, communication, existing social and cultural networks, decisionmaking, work and school settings, finances, sexuality/intimacy, caregiver availability/stress, and access to medicines and equipment.
30DOMAIN 5. SPIRITUAL, RELIGIOUS, AND EXISTENTIAL ASPECTS OF CARE PREFERRED PRACTICE 20Develop and document a plan based on assessment of religious, spiritual, and existential concerns using a structured instrument and integrate the information obtained from the assessment into the palliative care plan.
31DOMAIN 5. SPIRITUAL, RELIGIOUS, AND EXISTENTIAL ASPECTS OF CARE PREFERRED PRACTICE 21Provide information about the availability of spiritual care services and make spiritual care available either through organizational spiritual counseling or through the patient’s own clergy relationships.
32DOMAIN 5. SPIRITUAL, RELIGIOUS, AND EXISTENTIAL ASPECTS OF CARE PREFERRED PRACTICE 22Specialized palliative and hospice care teams should include spiritual care professionals appropriately trained and certified in palliative care.PREFERRED PRACTICE 23Specialized palliative and hospice spiritual care professionals should build partnerships with community clergy, and provide education and counseling related to end-of-life care.
33DOMAIN 6. CULTURAL ASPECTS OF CARE PREFERRED PRACTICE 24Incorporate cultural assessment as a component of comprehensive palliative and hospice care assessment, including, but not limited to: locus of decisionmaking, preferences regarding disclosure of information, truth telling and decisionmaking, dietary preferences, language, family communication, desire for support measures such as palliative therapies and complementary and alternative medicine, perspectives on death, suffering and grieving, and funeral/burial rituals.PREFERRED PRACTICE 25Provide professional interpreter services and culturally sensitive materials in the patient’s and family’s preferred language.
34DOMAIN 7. CARE OF THE IMMINENTLY DYING PATIENT PREFERRED PRACTICE 26Recognize and document the transition to the active dying phase and communicate to the patient, family, and staff the expectation of imminent death.PREFERRED PRACTICE 27The family is educated on a timely basis regarding signs and symptoms of imminent death in a developmentally, age-, and culturally appropriate manner.PREFERRED PRACTICE 28As part of the ongoing care planning process, routinely ascertain and document patient and family wishes about the care setting for site of death, and fulfill patient and family preferences when possible.
35DOMAIN 7. CARE OF THE IMMINENTLY DYING PATIENT PREFERRED PRACTICE 29Provide adequate dosage of analgesics and sedatives as appropriate to achieve patient comfort during the active dying phase and address concerns and fears about using narcotics and of analgesics hastening death.PREFERRED PRACTICE 30Treat the body post-death with respect according to the cultural and religious practices of the family and in accordance with local law.PREFERRED PRACTICE 31Facilitate effective grieving by implementing in a timely manner a bereavement care plan after the patient’s death when the family remains the focus of care.
36DOMAIN 8. ETHICAL AND LEGAL ASPECTS OF CARE PREFERRED PRACTICE 32Document the designated surrogate/decisionmaker in accordance with state law for every patient in primary, acute, and long-term care and in palliative and hospice care.PREFERRED PRACTICE 33Document the patient/surrogate preferences for goals of care, treatment options, and setting of care at first assessment and at frequent intervals as conditions change.
37DOMAIN 8. ETHICAL AND LEGAL ASPECTS OF CARE PREFERRED PRACTICE 34Convert the patient treatment goals into medical orders and ensure that the information is transferable and applicable across care settings, including long-term care, emergency medical services, and hospitals, such as the Physician Orders for Life-Sustaining Treatments (POLST) Program.
38DOMAIN 8. ETHICAL AND LEGAL ASPECTS OF CARE PREFERRED PRACTICE 35Make advance directives and surrogacy designations available across care settings, while protecting patient privacy and adherence to Health Insurance Portability and Accountability Act (HIPAA) regulations, e.g., by Internet-based registries or electronic personal health records.
39DOMAIN 8. ETHICAL AND LEGAL ASPECTS OF CARE PREFERRED PRACTICE 36Develop healthcare and community collaborations to promote advance care planning and completion of advance directives for all individuals, e.g., Respecting Choices, Community Conversations on Compassionate Care.PREFERRED PRACTICE 37Establish or have access to ethics committees or ethics consultation across care settings to address ethical conflicts at the end of life.
40DOMAIN 8. ETHICAL AND LEGAL ASPECTS OF CARE PREFERRED PRACTICE 38For minors with decisionmaking capacity, document the child’s views and preferences for medical care, including assent for treatment, and give appropriate weight in decisionmaking. Make appropriate professional staff members available to both the child and the adult decisionmaker for consultation and intervention when the child’s wishes differ from those of the adult decisionmaker.
41What’s Next?Next step for NQF is to get the document into wide useCall for palliative care programs to use this framework as their guidelines for quality palliative careCall for measures, based on these 38 preferred practices
42What can hospices do? Compare to hospice practice and NHPCO Standards Position in the communityBroaden beyond the Medicare Hospice Benefit
43Where to get Guidelines and Framework to download Guidelines for free.for information on ordering the full version of the Framework.For more information, contact the NCP office at