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Large hospice converted to palliative care philosophy
Continuum of care from home care to hospice
Heartland Home Health Care and Hospice, based in Toledo, OH, began to look seriously at palliative care in 1999, starting with research into how the 110-office organization could improve chronic disease management.
"We wanted to help our more fragile patients who were living with chronic diseases," says Lin Pekar, RN, BA, CHPN, CLNC, director of palliative and chronic care.
"We decided palliative care would be our strategy for getting better financial and clinical outcomes for these tough populations," Pekar says.
There were few palliative care programs tied to home care at the time, and hospice leaders saw this as an opportunity to improve the continuum of care.
"If we had a patient in home care one day who was transitioned to hospice the next day, then our vision for helping the patient really changed because hospice was so holistic," Pekar explains.
Once home care patients became hospice patients they received aggressive symptom management and psychosocial and spiritual care, she adds.
"We found ourselves asking, 'Why do patients have to be in the last six months of life before they receive services that help the chronically and terminally ill?'" Pekar says. "So we saw the value of upstreaming those services into our home care."
When home care services shifted to the PPS reimbursement model, Heartland decided to move away from a purely nurse-driven model and change it to an interdisciplinary care model, Pekar notes.
"We decided to put a social worker on those cases and make spiritual care available to patients having spiritual suffering," Pekar says.
"It's not like a patient suddenly becomes eligible for hospice and then lives with grief and loss," she adds. "These patients have been living with loss and grief, sometimes for years, before receiving hospice care."
So each patient who enters home care is assessed for palliative needs, such as pain management and comfort issues.
"We redesigned home care services to be palliative and interdisciplinary, and over the next three years we saw a significant improvement in our clinical outcomes," Pekar says. "Interestingly enough, we were able to do it under the PPS reimbursement model."
People often ask Pekar how the organization is able to make palliative care work for the bottom line. "When you start meeting patients' true needs, the financials follow," Pekar says in answer to this question.
"What's unique about Heartland's approach is we didn't make palliative care a bridge program, and it's not a specialty program," Pekar explains. "It's our philosophy of care and our belief that all patients, to some degree, will benefit from holistic care."
Here are some of the ways Heartland has made palliative care work:
• Work within payment structure: PPS reimbursement is episodic, giving an organization X amount of dollars for a 60-day episode of home care, Pekar explains.
"In the old days, you were paid every visit, but now you're paid for a 60-day episode, and the way they determine the money is with an assessment of the severity of the patient," Pekar says.
So when the home care agency receives X amount of money to care for a cardiac patient for 60 days, it's up to the agency to decide how they'll spend that money for services for this patient, Pekar explains.
"While the majority of home care agencies will provide nurse-driven care, almost to the exclusion of psychosocial and spiritual care, we approach the patient's care in an interdisciplinary way and bring in a team," Pekar says. "There may be a few less nursing visits, but we'll bring in a social worker and spiritual care counselor when we identify spiritual emptiness or suffering."
• Make suffering the sixth vital sign: If pain is the fifth vital sign, then suffering is the sixth, and Heartland has staff measure patient's suffering, using a tool that was adapted from one developed by Barry Banes, a national expert on suffering.
"Our suffering initiative started three years ago," Pekar says. "It's a natural topic and a language we all share now."
Patients describe their suffering, and the suffering assessment helps the palliative care team determine how best the patient can be helped, she says.
Just like with other symptoms, it's first identified, and then the team makes a care plan and monitors the intervention, Pekar says.
Suffering can intensify physical symptoms and feelings of sadness and isolation, she says.
"Why do patients repeatedly go back to the ER?" Pekar says. "It can be due to physical symptoms, but it can also be due to anxiety and feelings of sadness and isolation."
By bringing in a palliative care team's social worker soon after a patient's suffering is identified, it helps to reduce the patient's ER visits and it helps to keep the patient at home, Pekar says.
"In home care you better be doing that as much as possible because that's a tremendous focus in home care," Pekar adds.
• Identify fragile patients: "The other thing we also have put in place are processes to identify what we call 'fragile patients,'" Pekar says.
"Fragile patients are those who are more advanced in their disease process," Pekar explains. "They may or may not be hospice eligible, but they're tooling along in that direction."
These patients are linked early with the hospice staff for education about hospice services, and there are compassionate discussions about their goals of care, Pekar says.
"So very early on, the social worker will ask them if they'd like to know about hospice services that could serve them in the future," she says.
Hospice staff are the most passionate about hospice services, and they often can identify eligible patients and help with the transition to hospice care, Pekar adds.
• Form partnerships: Heartland Home Health Care and Hospice has a partnership with HCR ManorCare, a national long-term care and short-term post-acute medical care company, which is owned by the same health care parent company as Heartland. So nursing home care is part of the palliative care continuum of care.
"We work closely with their skilled nursing centers, offering hospice services, and we also work with hospitals," Pekar says.
About one-quarter of the hospice census includes patients in the long term care company's buildings, Pekar adds.
• Coordinate care: When the home care staff identify a fragile patient, and a hospice worker is sent in to speak with the family and patient, there is a coordination of care that takes place, Pekar says.
"Home care and hospice get together, and the key topic is who are the patients who we see as needing a transition, so we can put a plan in place," Pekar says. "We try to approach this in a way that is as seamless as possible, so the patient doesn't feel like he's switching to a whole new company."
Often when the hospice employee first goes out to the home to meet the family, it is a joint visit with a home care nurse, so the patient doesn't feel that it's just a stranger coming to his home, she explains.
"The home care and hospice nurses will meet there together and have a joint presentation, so the patient gets to know the new nurse through someone he already knows," Pekar says.
"The main services we try to bring over to home care is for our social worker with psychosocial care and the opportunity for spiritual care and bereavement care," Pekar says.
"Advanced care planning is another huge passion of ours, and we go beyond the advanced directive form," Pekar says. "It's about having passionate discussions about where you are in the health care journey, and what's important to you."
This could be aggressive pain and symptom management, as well as emotional and social issues, she adds.