1. Long Term Healthcare Conference May 13, 2010 Hospice & Long Term Care Working Together to Improve End-of-Life Care Ann Hablitzel RN, BSN, MBA Hospice Care of California

2. Program Objectives Discuss services provided Questions to help address the challenges of providing hospice care in a long term care facility How to apply practical strategies for building the relationship

3. Nursing Facility as Site of Death By 2020, it has been estimated that 40% of Americans will die in a nursing facility Some states have nearly met that level

4. Philosophy and Guiding Principles of Hospice Hospice recognizes dying as a natural part of life and focuses on maintaining the quality of remaining life. Hospice affirms life and neither hastens nor prolongs the dying process. The nature of dying and of human suffering is understood to be a fundamentally personal experience based on cultural and spiritual traditions.

5. The Role of Hospice To support the cultural and spiritual orientation of the patient and family To demystify the dying process To assist with resolution of interpersonal and internal conflicts before death To help attain a degree of peace in their search for the meaning and purpose of their lives To help the patient and family achieve a positive end-of-life experience that is defined by them

6. Eligibility Two physicians must certify that the patient is terminally ill with a life expectancy of six months or less if the disease follows its normal course. Patient and/or family are aware of the prognosis and elect palliative care rather than curative measures.

7. Medical Conditions Appropriate for Hospice Care Cancer Heart Disease COPD Dementia/ALZ Stroke MS Renal Failure Hepatitis Debility Unspecified

8. Hospice Care for Seniors (Medicare Eligible) An HMO senior plan member is still eligible for the Medicare hospice. For ALL senior health plans, Medicare pays for Hospice - which eliminates the authorization process - which can take too much time when the patient needs care.

9. Five Domains of Care 1.Relieving pain and symptoms 2.Avoiding a prolonged death- relieving suffering 3.Maintaining control - their choices honored 4.Relieving others of the burden of care 5.Strengthening relationship Singer and Colleagues

10. Services Provided by Hospice Care of California Visits from interdisciplinary team Medications related to the patient’s hospice diagnosis Durable medical equipment Dietary counseling Spiritual counseling Volunteer support PT, OT, ST, as necessary to improve comfort/function Bereavement services for up to one year following the patient’s death

11. Interdisciplinary Team Attending Physician Hospice Physician RN Case Manager Social Worker Home Health Aide Chaplain Volunteer

12. Levels of Care Routine Level Respite Level Inpatient Level Continuous Care

13. New COPs – History of Discomfort “The provision of, and questions related to, hospice care for residents of those facilities has come under scrutiny as a result of a variety of report findings…” Preamble, Hospice Conditions of Participation Federal Register – June 5, 2008

14. New COPs - §418.112 Incorporated language and concepts from previous sub-regulatory releases Did not clarify the areas that have always been puzzling Created concern because hospices now have regulations and SNFs/NFs do not

15. In the Middle of Difficulty Lies Opportunity Albert Einstein

16. §418.112(b) Professional Management Based on the hospice plan of care and the Medicare regulations, hospice must assume responsibility for professional management of all hospice services provided. The Reality

17. Challenging Component Both parties must continue to provide services at the same level that they would have if the other partner were not involved. Hospice must only use facility personnel to carry out the Plan Of Care to the extent that they would use family.

18. §418.112(d) Hospice Plan of Care A written care plan must be established and maintained in consultation with facility representatives All care must be provided following this plan

19. Challenging Component Where shall we start? One or two care plans? Care Plan coordination is a common logistical problem. The burden is really on the Hospice.

20. Successful Communication Define the Chain of Communication Between Hospice and Facility In the event a crisis or emergency develops Change of condition occurs Changes to the hospice portion of the plan of care For complaints and other issues

21. Top Success Factors Relationships at all levels Communication Provide excellent care – deliver what’s promised Responsive Adaptable Consistent Shared vision and values Respect Benefit to the patient

22. “You matter to the last moment of your life, and we will do all we can, not only to help you die peacefully, but to live until you die.” Dame Cicely Saunders

23. Thank You!! Hospice Care of California