1. Transitions : Pre-Hospice Support Susie Lyons, LCSW, AP Shirley Bloodworth, RN, BSN, MSN

2. Transitions: What is it? A Community Outreach Program providing support to individuals& families affected by chronic life-limiting illness. –Alzheimer’s DiseaseDementia –Heart Disease/Pulmonary Disease –CVA/Coma –Etc.

3. Transitions: Fit with Hospice of North Central Florida Network

4. Transitions Program Components  Phone support  community outreach  community education  volunteers

5. Meet Our Staff! Tim Bowen, Executive Director/COO Tim Bowen is the Executive Director/Chief Operating Officer of Hospice North Central Florida. He joined HNCF in January 2000. Prior to coming to HNCF, Tim was the director of Mid-Peninsula and Pathways Hospice, which served the San Francisco Bay area. He previously served as National Hospice Director of Hospice development for Olsten Kimberly Quality Care. Tim began his hospice career in 1985 as a social worker at the Kaiser Permanente Medical Center in Oakland, California. Susie Lyons, LCSW Transitions Coordinator Susie Lyons is the Transitions Coordinator at Hospice of North Central Florida. Susie joined HNCF in March, 2000. Prior to coming to HNCF, Susie worked as a social worker in Home Health Care and 15 years within the VA Health Care System from Nursing Home Care to Adult Day Health Care to long-term spinal Cord Injury care and Geriatric Psychiatric care. Susie covers 14 counties. selyons@hospicecares.org 1-800-330-2858 or (352) 2711-4648

6. Meet Our Staff! Shirley Bloodworth, RN, BSN, MSN Shirley Bloodworth is the Transitions Nurse for Alachua and Duval Counties. Shirley has been with Hospice over 10 years in many different roles. She is retired from the faculty of the College of Nursing, and was Nursing Director of the Clinical Research Center at the University of Florida. She has done advance work in the Counselor Education and Geriatric programs. She was Gainesville's Community Chair for the Coalition for "End of Life Issues,” and has helped develop an Advance Directive Workbook. sgbloodworth@hospicecares.org 1-800-727-1889 or (352) 379-2929 Kelly Hunter, RN is a Transitions Volunteer Kelly has been a Transitions volunteer nearly one year. She has been creating an educational book for clients and families on various end-of- life issues. She is also creating the Transitions Volunteer Training and Resource Manual. She is a PRN nurse with with Shands Teaching Hospital.

7. Hospice of Jacksonville Hospice of the Lakes Hospice of North Central Florida Hospice of the Suwannee Valley Hospice of the Tri-Counties Horizon Health Services Florida Palliative Home Care The Pegasus Program Healing Hearts Transitions The Hospice of North Central Florida network Serving 16 counties and spanning more than 10,000 square miles Care and Compassion When Needed Most

8. HNCF Network of Services Pediatric support program- medical, emotional & spiritual care for children, families, & the community (352)692-5138 Grief support program - counseling services to individuals, families, & groups affected by loss. (352) 379-6239 Home health care with expertise in disease & symptom management. (352) 379-6217 Home medical equipment (352) 379-6187 Outreach program - phone support & service referral for pre-Hospice patients (352) 271-4648

9. HNCF Network Teams Team A: HNCF, Gainesville Team B: Hospice of the Lakes, Palatka Team C: Hospice of the Suwannee Valley, Lake City Team D: Hospice of the Tri- Counties, Chiefland Team N: Facilities Team J: Hospice of Jacksonville Team L: Hospital Liaisons, Gainesville Team H: E.T. York Care Center, Gainesville Team S: Starke

10. Transitions: Making Referrals G’ville local # or Toll-free # No MD referral required No charge (funding sources: grants/donations/memorial contributions) Anyone can make referral –Pt., family, caregivers, clergy –Healthcare providers (hospitals/agencies, etc) –Friends, neighbors

11. What does Transitions provide to clients & their families?  Emotional support  Information about & referral to community resources or HNCF network services  Opportunity to share concerns related to life-limiting illness  Education on Advance Directives, Care-giving, Palliative Care, Hospice care  Focus on decision-making issues

12. End of Life Issues Those with Dementia –Long-term palliative care –Decision-making Caregivers/Families of those with Dementia –Responsibilities of caregivers –Difficult decisions regarding palacment Timing Appropriateness

13. Grief Issues Anticipatory Grief –Preparing for losses –Collaboration with Alz.Assoc., MFAAA, Geriatric Centers Healing Hearts –Bereavement programs Individual counseling Group Support Memorial programs

14. HNCF Network Cost/Payment sources Appropriateness for network services –Home care –Medical equipment –Hospice At home In facility (NH, ALF, Care Center)

15. Questions/Discussion