BON SECOURS HEALTH SYSTEM

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BON SECOURS HEALTH SYSTEM

• Building a System-Wide Foundation for Palliative
  Care
• Bon Secours Journey
• Maria Gatto, MA, APRN, BC-PCM, NP, HNP
• Director Palliative Care, Bon Secours Health
  System
• Supportive Care Coalition
• March 14th, 2007

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The Vision

• To provide integrative
• comprehensive holistic palliative
• care services across
• the continuum
• BSHSI Statement on Quality, 2004

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The Tragic Reality
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Objectives

• Understand the process of a system wide
  palliative care needs assessment across the
  continuum of care
• Identify the elements of a system-wide palliative
  care foundational support plan across the
  continuum of care
• Identify the palliative care patient and measure
  the outcomes across the continuum of care

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Bon Secours Health System Mission Statement The
Mission of 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. As a System of caregivers, we commit
ourselves to help bring people and communities to
health and wholeness as part of the healing
ministry of Jesus Christ and the Catholic
Church.
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Bon Secours Health System

• 20 Acute Care Hospitals
• 1 Psychiatric Hospital
• 6 Nursing Care Facilities
• 6 Assisted Living Facilities
• 2 Retirement Communities
• 6 Home Care and Hospice Providers

A 2.7 billion not-for-profit Catholic health
system, Bon Secours owns, manages, or joint
ventures
NY
M I
PA
MD
KY
VA
SC
Bon Secours more than 18,000 caregivers help
people in 11 communities in 8 states
FL
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Beginning the story of our journey
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Objective

• I. Understand the process of a system wide
  palliative
• care needs assessment across the continuum of
  care
• Palliative Care History within Bon Secours
• Identification of Current Status
• System Wide Palliative Care Assessment
• System Wide Palliative Care Process Results
• Key Findings
• Next Steps

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Timeline of our journey.

• 1992 Sisters of Bon Secours Statement on Care
  of the Dying
• 1999-2004 Care of the Dying Quality Plan
• Included element to develop Palliative Care Teams
  by 2002
• Care provision a local initiative only, often
  Mission driven
• 2004 Expansion of Palliative Care to Quality /
  Care Management
• Identification of BSHSI Palliative Care
  Demonstration Project Task Group
• Representatives from the HSO, Local System Care
  Providers
• Local System Leaders commitment for development
  of Palliative Care Service and establishment of a
  virtual center of excellence
• Charity, Greenville, Richmond, Hampton Roads
• 2005 Palliative care
• Director of Palliative Care Services hired
• Mission, Pastoral, and Local System Palliative
  Care Leaders included in planning
• Demonstration Project Task Group determined needs
  assessment process to identify palliative care
  baseline status system wide
• System wide assessment completed

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THE ASSESSMENT Chapter One
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Palliative Care Baseline Process Assessment

• Goal Establish baseline process measurement of
  palliative care services
• system wide across the continuum of
  care
• Evaluation Tool
• 12 Elements from BSHSI Palliative Care Quality
  and
• Business Plan
• Baseline Process Rating /Color Code System
• 3Present/Green
• 2Partially Present/Yellow
• 1Not Present/Red
• 28 Health Care Sites Assessed Across the
  Continuum
• 14 Hospitals
• 7 Nursing Homes
• 5 Assisted Living Facilities
• 2 Home Health Care Agencies

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Palliative Care Overall Process Scores
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KEY FINDINGS
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Successes Realized

• Baltimore Acute Care Dr. Neal Reynolds,
  Intensivist, established Palliative Care in the
  ICU, standing orders, redefined code status
  from DNR, Do Not Resuscitate, to AND, Allow
  Natural Death, a compassionate communication
  technique for palliative/hospice discussions
• Charity Education and Integration Grant
  funding All staff at St Anthony Community
  Hospital receives ELNEC, Palliative Care
  Education, Joie Ogrodnick, Patient Relations.
  Good Samaritan Hospital established integrative
  volunteer holistic nursing service team, Kathleen
  Lynam, VP Patient Services
• New York Grant Funding for Shervier Nursing Care
  Center Palliative Care Education for the Care of
  Dementia Patients, Paulette Sansone, PhD, LMSW
• Hampton Roads Continuum of Care Liaison role's
  of hospice nurses provides continuity of
  palliative care through all care settings, Robin
  Boothe, Director of Hospice/Home Care
• Florida Long Term Care Maria Manor Nursing and
  Rehabilitation Center Angels Passing By
  Program, unique end-of-life program, 24 hour
  compassion at the bedside, Martha Smith, ADON

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Top Foundational Issues Realized

• LACK OF PALLIATIVE CARE TEAMS
• INADEQUATE EDUCATION, CERTIFICATION PROGRAM
  DEVELOPMENT
• INCONSISTENT PALLIATIVE CARE POLICIES
  STANDARDS
• NO ESTABLISHED PALLIATIVE CARE METRICS OR
• MEASUREMENT SYSTEM
• LACK OF INTEGRATION OF PALLIATIVE CARE SERVICES
  ACROSS THE CONTINUUM OF CARE

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PHASE-IN PROCESS Chapter Two
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Objective

• II. Identify the elements of a system-wide
  palliative care foundational support plan across
  the continuum of care

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NEXT STEP Phase 1 Accountability

• Building the Foundation Through
• Engagement
• Leadership
• Team Building
• Education
• Policy and Procedure
• Outcomes
• Integration
• IT/Electronic Support

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Building the Foundation Through

• Engagement
• Presentation of results system wide to corporate
  and local system leadership
• Executive Management Team Presentation
• Board Quality Presentation
• Mission Leadership Presentation
• Local System Leadership Presentation
• Palliative Care System Wide Presentation
• Leadership
• Create unified interdisciplinary leadership body
  
• Development and Establishment of Palliative Care
  Charter and Advisory Council
• Team Building
• Financial Planning Expectation
• Required Budget Items for FTEs

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Building the Foundation Through

• Education
• Set standard for Team Professional Licensure,
  Training, Education
• EPEC, ELNEC, Board Certification, CAPC/PCLC, ACE
  Project, On-Line Web Based Educational Programs,
  Wellspring
• Policy and Procedure
• Develop system wide policy to meet national
  compliance standard
• Policy Task Force Team
• Identify National Standards JCAHO and CAPC
  Crosswalk
• Create Minimal Standard Set inclusive of BSHSI
  perspective
• Local and Corporate Review and Approval Process
• Outcomes
• Identify and establish standard outcomes
  measurement, data collection, reporting, and
  improvement process
• Palliative Care Dashboard
• Mortality Review BSHSI Definition of Mortality,
  Zero Preventable Deaths Palliative Care
  Bundle

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Building the Foundation Through

• Outcomes (continued)
• Integrative Holistic Palliative Care Assessment
• Initial, Daily, Final Quality Outcome Assessment
• Supportive Care Coalition National Data
  Collection and Benchmarking System for Spiritual
  Palliative Care Assessment
• Palliative Care Patient Trigger
• National Palliative Care Pilot NHPCO Quality
  Partner Initiative
• Integration
• Connecting palliative care across the continuum
• Integration with Outcomes Management SOFTMED
• Development of Identification and Reporting
  Processes for palliative care residents through
  EQUIP / MDS Softwear
• IT Support
• Knowledge share through intranet
• IRIS Palliative Care Collaborative Page

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QUALITY OUTCOME MEASUREMENT Chapter Three
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Objective

• III. Identify the palliative care patient and
  measure the
• outcomes across the continuum of care

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Palliative Care Dashboard
BSHSIs FY07 Strategic Quality Plan
Key Strategies
Goal
Outcomes
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Palliative Care Dashboard Indicator
Determination and Reference Base

• Benchmarking indicators limited due to
• New specialty
• Research data limited - none
• CAPC The Center to Advance Palliative Care
• National initiative supported by The Robert Wood
  Johnson Foundation, named national leader, Mount
  Sinai School of Medicine, (NY)
• Only national organization to establish accepted
  benchmark
• Estimated number of potential palliative care
  patients based on an estimated 5 of annual
  discharges
• Assumed potential of palliative care patients
  based on experience of palliative care program
  increasing over time
• BSHSIs First Year Trial 1.0
• System Wide Goal Met
• 1,970 Total Number of Palliative Care Consults as
  of January 2007
  
  
  
  
• http//www.capc.org/ http//www.capc.org/about-c
  apc/faqs
• http//www.capc.org/impact_calculator_basic/
• http//www.capc.org/impact_calculator_detailed/

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Mortality Review

• IHI Analysis of Mortality information reveal 3
  common themes
• Failure to plan (diagnosis, treatment appropriate
  care and end of life)
• Failure to communicate (between caregivers and
  covering physicians/consultants) inadequate
  documentation
• Failure to rescue/recognize (change in condition
  not recognized)
• Overarching aim of SPQ, Strategic Quality Plan
• Zero Preventable Deaths by 2009
• Goal achieved by
• Incorporating the IHI Mortality Reduction
  Strategy
• Further define Preventable Deaths by examining
  3 categories of death
• Anticipated
• Unanticipated
• No Failure

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Mortality Review

• First Mortality Study 14 Hospitals reporting
  N687
• Local System Mortality Results Report Related to
  Palliative Care
• Lack of pc identification, intervention, end of
  life discussions
• Inappropriate transfer to ICU (perception of ICU
  focus group)
• Lack of end of life discussions with
  patient/family
• Outcomes
• System wide trend identified Lack of palliative
  care service
• Action to implement palliative care teams
• Development of new bundle tool to add to
  Mortality Review Process Palliative Care Screen
  and Bundle Tool
• Second Mortality Review 96 Palliative Care
  Screen and Bundles
• 93 out of the 96 palliative care screens met
  potential of palliative care consult Average
  score 7.6 (gt 4 consider palliative care consult)
• No Palliative Care appropriate patients had
  completed bundle criteria
• Day 1 Decision maker established Advanced
  directives addressed
• Day 3 Pain managed optimally, Social support,
  Spiritual support
• Day 5 Family goal planning meeting completed

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DNR Status Before Day of Death
60 patients were placed on DNR status one day
before death another 47 on the day of death
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Days Between Advance Directive Death
Advance Directives most commonly occurred on
1.5-2.0 days before death
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Identify Palliative Care Patient

• Known Supportive Processes
• Establishing palliative care services,
  collaborative relationships, trust
• Increased staff education
• Daily Huddles
• Attending Care Management Rounds
• Known Barriers
• Culture change difficult
• Lack of education Hospital staff, community,
  patients/family
• Limited staff, time, resources
• New service development
• Poor communication Departmental silos,
  fragmented care
• Lack of identification on admission,
  re-admission, and late referrals

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Challenge Create New Electronic Processes

• Created Project Team HSO/Local Clinical,
  Operational, IT Systems
• Created process map of multiple interfaces
• Identified integration with Process Redesign
  Project led by Barbara
• Oot-Giromini, Director Outcomes Management,
  HSO, joined project team
• SOFTMED- electronic medical record system used to
  improve care management processes by redesigning
  process information flow to increase efficiency
  connecting patient to all levels of care.
  Identified appropriateness to integrate
  palliative care identification / referral process
• Manual screening tool identified CAPC Screening
  Tool
• Determine which part of process tool utilized,
  and create alert screen when criteria met,
  (pilot in care management successful)
• Created electronic referral between care
  management and palliative care coordinator,
  worklists, and electronic progress note template
  for palliative care coordinator
• In development automatic alert to identify
  patients on readmissions, screening tool, and
  bundle review, initial, daily and final
  assessment screens
• Pilot site determined Hampton Roads

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ALERT to care managers to contact Attending to
discuss need of palliative care referral and
discuss with palliative care team when screen
tool is a score of 4, and/or alert flag D, Y,
N Key D Declined, Y Yes, had consult on
previous admission, met criteria N No, met
criteria, no previous palliative care consult
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CAPC Screening Tool Pilot To be integrated in
nursing admission, or relevant history screen to
be done by care managers
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Palliative Care Referral Screen
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Palliative Care Worklist
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Palliative Care Bundle Bundle screen is for the
palliative care coordinator to complete for all
patients part of the palliative care service
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Palliative Care Initial Assessment
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Palliative Care Assessment Initial Assessment
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Palliative Care Assessment Initial Assessment
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Palliative Care Assessment Daily Rounding
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Palliative Care Assessment Daily Rounding
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Palliative Care Assessment Daily Rounding
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Palliative Care Assessment Daily Rounding
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Palliative Care Assessment Final
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Palliative Care Assessment Final
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Palliative Care Assessment Final
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Palliative Care Outcome Sample Reports
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Palliative Care Outcome Sample Reports
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Palliative Care Outcome Sample Reports
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Palliative Care Outcome Sample Reports
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Palliative Care Outcome Sample Reports
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Palliative Care Outcome Sample Reports
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Palliative Care Outcome Sample Reports
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Integrative Spiritual-Palliative Care Assessment

• Need Identified Interdisciplinary Palliative
  Care System Wide Leadership, Mission Leader
  Guidance
• Project Team Created
• Goals Objectives Determined
• Short Term Goal To Identify Spiritual Palliative
  Care, SPC, outcomes measurement process
• Long Term Goal To identify overall reportable
  dashboard metric
• Objectives
• Identify SPC assessment tools
• Identify SPC data collection process
• Identify SPC reporting process
• Identify Bereavement assessment tool
• Identify Bereavement data collection process
• Identify Bereavement reporting process
• Tools/Data Collection/Reporting Process
  Identified Supportive Care Coalition City of
  Hope Quality of Life Assessment and Benchmarking
  Program
• Next Steps Pilot Planning

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National Palliative Care Pilot

• National Hospice and Palliative Care Organization
  Quality Partner Initiative
• BSHSI accepted as the only National Palliative
  Care Pilot to work in partnership with the NHPCO
  the Centers of Medicare and Medicaid to assist
  in a study for the determination of future
  Hospice Care CMS measures
• Quality Partners 10 Components of Focus
• Patient Family Centered Care
• Ethical Behavior Consumer Rights
• Clinical Excellence Safety
• Inclusion Access
• Organizational Excellence
• Workforce Excellence Safety
• Standards
• 7 out of 15 BSHSI Hospitals part of National
  Initiative

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National Palliative Care Pilot

• Charity System St. Anthony Community Hospital,
  Good Samaritan Hospital, Community
• Hospital
• Component Patient and Family Centered Care
• Focus Pain and Symptom Management
• Goal Reduce patients/residents discomfort by 50
  within 48 hours of admission to the Palliative
  Care Service
• Kentucky System Our Lady of Bellefonte Hospital
• Component Ethical Behavior and Consumer Rights
• Focus Advanced Directives
• Goal Documentation that Advanced Directive are
  addressed 48 hours of admission to Palliative
  Care Service for 90 of patients
• Richmond System Memorial Regional Medical
  Center, St. Marys Hospital, Richmond
• Community
  Hospital, St. Francis Medical Center
• Component Patient and Family Centered Care
• Focus Goals of Care
• Goal Develop, document, and communicate, those
  Goals of Care that address the Palliative Care
  Bundle for 75 of patients

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What this journey is all about Final Chapter
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