Patients flow seamlessly from hospital to hospice
Interdisciplinary team eases continuity of care
Summa Health System in Akron, OH, takes an interdisciplinary approach to the care of terminally ill patients, providing seamless support across the continuum of care, says Diane Siddall, RN, CHPN, case manager with Hospice of Summa.
"The biggest problem in any system is the hand-off between hospitalization and hospice. We have created a seamless process so that patients continue to receive the support they need whether they're in the palliative care unit or at home," Siddall says
Summa's hospice interdisciplinary team includes RN case managers, home health aides, social workers, the spiritual care team, and board-certified hospice physicians, as well as assessment nurses who conduct the assessments in the hospital's palliative care unit. The hospice care team has its own pharmacist, who can give advice on pain management and symptom control.
"Hospice is a natural progression for many of the patients in Summa's palliative care unit. We work closely with the nurses and case managers in that program so that the handoff is very easy when patients come to the end of treatment that will be useful for them," she says.
The interdisciplinary team meets once a week to discuss the care plan for all of the patients who are receiving hospice services. For instance, if a patient who is receiving hospice care in the home has problems and needs pain management, he or she can be transferred to the palliative care unit.
The hospice case managers are assigned by geographic area to give the nurses more time to spend with patients instead of traveling.
Referrals from the hospice program come from physicians or sometimes family members who have read about hospice care or have friends who have experienced it.
"The public is much more educated about hospice care now than a few years ago," she says.
Siddall sees her role as doing whatever is needed to make the patient comfortable and able to function at his or her highest level, whether that means providing emotional support or bringing in equipment.
"People can't deal with their emotional and family issues at the end of life when they are distracted by a lot of pain. My role is to go into the home and get the symptoms under control and provide support so that the patients can interact with the people they love and do some of the things they want to do without suffering," she says.
For instance, patients with end-stage congestive heart failure can do well in hospice because they have someone helping them manage their symptoms and someone they can call when they get in trouble instead of ending up in the emergency department.
"We can help with symptom management or just provide someone to talk to. We provide small doses of narcotics in the home that gives the family a tool so they don't need to bring the patient to the emergency room. They can have one of our on-call nurses come in to help if needed," she says.
Summa's hospice team is working to educate the hospital's physicians about the kind of services that hospice can provide and to help them learn how to present the idea of hospice to families.
"Our physicians are being trained now to understand what kind of services that hospice can provide," she says.
The hospice team works with physicians to help them learn how to present the idea of hospice to the family so that the patient and family can receive the services before the patient is in an end-of-life crisis situation.
"One of the biggest problems is that patients don't get into hospice soon enough. We present hospice as a way to help with symptom control and give the family support," she says.
When Siddall gets a referral, she makes an appointment with the family and friends of the patient and presents the program.
"The most important thing is to help the family understand that we are there to support their goals. The patient and family determine what they want to happen, and we support them in their choices," she says.
She assesses the family's knowledge about hospice and makes sure that they are ready for a regime that does not attempt to prolong life but keeps the dying person as comfortable as possible.
"We also provide volunteers to help with caregiver respite and patient companionship. Most times when families are admitted to hospice, they have been the sole caregiver for an extended period of time, so it's a relief for them to have our volunteers available," she says.
When she assesses the patient and family, Siddall determines what kind of services they will need, such as home health aides for personal care. If the family doesn't have a church home and wants spiritual care, she calls in Summa's chaplain.
"If the patients are lonely and don't have anyone to visit with them, we can bring in volunteers. If they have aches and pains that aren't related to their terminal illness, we can bring in a massage therapist," she says.
When the program first began, the case managers performed all the assessments. Now that the caseload has increased, the case managers can call on the assessment nurses to make the initial assessment and contact physicians for the initial order.
"I like to open my own cases. It's a very intimate time. It takes a few visits to catch up on knowing the patient and family if I don't open the case," she says.
The assessment typically takes two to four hours and includes consent forms and other paperwork but, most importantly, gives the case manager a chance to learn about the family.
"I begin by asking the patient and family to tell me their story. I need to hear in their words what they've been through so I can determine how I should work with the family," she says.
Siddall visits most of her patients twice a week unless they're having problems, such as symptom control.
She gives the family "care kits," sealed bags with small doses of medications that they can use to keep the patient comfortable.
"We give the patients and families a lot of education. We have a home folder with information on medication management and how to use the comfort medications. We encourage them to call hospice and let us walk them through the medication use if they experience new symptoms during the night that require intervention," she says.
She goes over the medical equipment and assesses the home for safety issues.
She does an assessment every time she visits the patient.
"As they decline, it's not a static situation. I prepare them for when they start having ambulatory problems. Falls are dangerous for the hospice situation, and prevention is a major goal as broken bones often require hospitalization," she says.
She stays in touch with her patients' physician, reporting any changes in the patients' conditions and getting orders for additional medications, if appropriate.
Most of the time, the patient's primary care physician remains his or her managing doctor under the hospice program. In addition, Summa's Palliative Care and Hospice Services physicians can make home or nursing home visits or assist with pain management if the primary care physician desires, Siddall adds.
The hospice team can get medications filled at the hospital and have a pharmaceutical courier deliver them. The on-call nurses or home health aides also deliver medications when they visit.
The program has more than 100 patients in home hospice care. Another team manages the care of hospice patients in nursing homes.
"If we can build a relationship with the nursing home and they get comfortable with one person coming in to see the patient, there is better communication between the nursing home and the hospital," she says.
Summa Health System in Akron, OH, takes an interdisciplinary approach to the care of terminally ill patients, providing seamless support across the continuum of care, says Diane Siddall, RN, CHPN, case manager with Hospice of Summa.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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