Evercare Quality Improvement Awards

1
Evercare Quality Improvement Awards

• James Collins, M.D.
• Julie Hayes, R.N.
• Randy Muenzner

2
Faculty Disclosures

• Dr. Collins
• Medical Director, Evercare
• Pfizer Pharmaceuticals Speakers Bureau
• Eisai Pharmaceuticals Speakers Bureau

3
Learning Objectives

• By the end of the session, participants will be
  able to
• Understand the need for improved End of Life
  practices in Long Term Care Facilities
• Identify barriers to End of Life Care
• Identify end stage disease indicators
• Understand how the Modified Flacker Mortality
  tool can be incorporated into existing facility
  practices

4
Facility Demographics

• Elderwood Healthcare at Maplewood
• Cheektowaga, NY
• 160 Beds (138 long term/22 subacute)
• Private Owner

5
Palliative Care Process Improvement

• Problem
• Recognition of terminal status for residents with
  chronic illness occurring late in disease
  process.
• Little or no time for families/residents to make
  informed decisions.
• Little or no time for staff to plan or implement
  quality palliative interventions.
• Poor outcomes.

6
Modified Flacker Mortality Scale

• Objectives
• Provide nurses/physicians with an accurate,
  objective tool to monitor progression of disease
  process.
• Provide nurses/physicians and families with time
  to review residents status, advanced directives
  and options for treatment.

7
End Stage Disease Indicators

• Resident characteristics assessed on Flacker
  Mortality Scale
• - Functional ability (ADL Score)
• - Weight Loss
• - Shortness of Breath
• -Swallowing Problems
• - Sex (Male at higher risk)
• - CHF
• - Age
• Found in our study to be an early sign of
  decline.

8
Project Timeline

• Study began October 2005
• Funded by Community Health Foundation as a
  collaborative endeavor with Hospice of WNY and
  Elderwood Healthcare at Maplewood.
• Began on one unit with 40 residents
• Flacker Tool
• Later modified to exclude residents with advance
  directives for aggressive care. Subsequently
  identified as the Modified Flacker Tool.
• Study ended December 2006
• -Completion of Modified Flacker assessments
  to all long term care residents.
• January 2008
• Policy was implemented in all Elderwood Senior
  Care facilities covering over 1300 LTC residents.
  

9
QI Planning Implementation

• Leadership
• Dr. James Collins, Medical Director
• Julie Hayes, Assistant Director of Nursing
• Informal weekly meetings from 10/05 to 12/06
• Facility wide implementation 1/07
• (4) Unit Managers
• MDS Coordinators
• 30 minutes weekly per nurse manager
• Communication
• Informal introduction to interdisciplinary staff
  over a period of time.

10
Modified Flacker Assessment

• How was study conducted?
• - Formatted Modified Flacker tool into User
  Defined Assessment Software.
• Issues encountered how they were overcome
• - Staff resistant to change. Residents
  identified by the tool didnt look like the type
  of End of Life Resident with whom staff were
  familiar.

11
Tools Used to Affect Change

• Tools used
• Information obtained from last MDS completed.
• Assessment schedule follows MDS cycle.
• Tools created
• Modified Flacker Form

12
Facility Expenses

• No significant expenses incurred.
• After initial education and implementation
  individual nursing time to complete weekly
  assessments is approximately 15 minutes.
• No additional staff needed.

13
Outcomes

• Resident Outcomes
• Facilitates residents to prioritize needs and
  wishes.
• Advanced directives established.
• Resident family directed plans of care.
• Residents family emotionally prepared.
• Regulatory Outcomes
• Care plans are accurately prioritized.

14
Outcomes

• Improved Quality of Service
• Priority is determined by the residents
  preferences with proper education of possible
  outcomes.
• More effective Pain Management.
• Proactive Advance Care Planning eliminates futile
  and inappropriate treatments.
• Spiritual and Emotional needs of both resident
  and families are identified and addressed by the
  interdisciplinary team including the Chaplain.

15
Outcomes

• Enhance Staff Performance
• Early identification of the terminally ill
  resident enables staff to gain more insight into
  the special needs of the resident and family.
• Improved quality of life at the end of life has
  enhanced job satisfaction.
• Effect on Staffs every day routine work
• Created a culture within the building to allow
  for all involved to be comfortable with the dying
  process.

16
Outcomes

• Improved organization management structure
  systems
• Modified Flacker Tool is completed at the same
  time an MDS is completed. Staff member
  experiences no additional work load.
• Clear and timely approach to establishing a
  Palliative Plan of Care.
• When implementing you are only establishing a
  measurement tool to identify when a Palliative
  Plan of Care should be activated.
• No change in current Palliative Plan of Care nor
  staffing needs.

17
Outcomes

• Financial Outcomes
• Revenue neutral for the facility.
• Cost savings to the health care industry by
  reduction in unwanted hospitalizations.

18
Closing Thoughts

• What is the feasibility that this project could
  be implemented at other facilities?
• Feasibility is simple. Has been implemented in 9
  more facilities.
• Lessons Learned
• How easily culture change occurred when this
  process was implemented. There was buy in from
  staff, residents and families.
• Helpful Tips/Insights
• One individual can impact an entire facility when
  they bring forth an idea whose time is come.
• Any Questions?