New York hospice's QI project yields improvement in LOS
Education and training are crucial
The Center for Hospice and Palliative Care in Cheektowaga, NY, has a head start on many other hospices in the effort to develop quality improvement projects that will pass muster with the Centers of Medicare and Medicaid Services when the new Conditions of Participation are published in two years.
The New York hospice already has a year-old performance improvement, pilot project that shows positive results.
The project involves collaboration with a local senior care company's long-term facility, bringing hospice care to the building's residents on a more structured basis than had been done before.
"What we found was the number of referrals has not gone up significantly, but the length of stay (LOS) ahs gone up," says Kathy Chowaniec, RN, a hospice/nursing home/professional relations liaison.
From the first quarter of 2005 to the first quarter of 2006, the hospice had a 25 percent increase in LOS within the building where the QI project is being conducted, Chowaniec says.
Before the QI project, the trend was for LT staff to make a hospice referral after a patient showed obvious changes in condition or entered a crisis mode, Chowaniec notes.
"That's when the facility staff or physicians would contact hospice for collaboration," Chowaniec says. "We were hoping to change that awareness, so they'd notice the subtle declines and allow the residents earlier access to hospice."
Other positive results included a zero hospitalization transfer rate among the patients referred to hospice through the program, and the hospice and LT facility were able to meet 100 percent of the patient's wishes, Chowaniec says.
"Whatever their choice in pursuit of care or declining hospice, the facility through this process has been able to make sure that what they want is what they're getting," Chowaniec adds.
Here is how the hospice's QI process worked:
- Identify a need: In the summer of 2005, a local community health foundation asked organizations for ideas on how to improve outcomes for elders in the community, Chowaniec recalls.
As a result of this, the hospice approached ElderWood Senior Care and asked the company to take the relationship the hospice already had with the long-term care facility to another level in order to provide more thorough hospice referrals to LT care patients. Once the two organizations agreed on this idea, it was submitted as a proposal to the community health foundation, and the idea was accepted, Chowaniec says.
- Propose a change: The goal was to improve hospice access to LT care patients. Although patients were referred by LT physicians and staff, there was no structured process for hospice referrals, so the QI team identified an assessment tool that might help improve the process.
The Flacker mortality assessment scale provided risk assessment for the likelihood of a LT patient's death within one year, based on specific elements of the Minimum Data Set (MDS). The assessment scale looks at social engagement, among other qualities.1
"Flacker and colleagues identified that if you were able to use the MDS measures you could link a person to better, enhanced, end-of-life services that were likely to include hospice," Chowaniec says.
"We knew that tool was out there, and we knew some hospices on the West Coast had implemented a use of the tool, and we wanted to do the same thing," Chowaniec says.
So the hospice and LT care QI team linked specific MDS data with the Flacker assessment tool, using the collaboration in such a way that met all regulatory standards for privacy.
"To date, I go into the facility weekly and work with a representative of the long-term care facility who is also on my [QI] team," Chowaniec says.
- Analyze process and results: "Initially, our direct goal was to implement this tool to help facility staff identify decline and allow them to put certain things in motion," Chowaniec says. "We were naïve and soon realized we needed to help them put these things into a protocol."
Also, the tool has been modified three times as a part of the collaboration, she says.
"At different parts of the process, we decided there were certain elements that didn't work for us, and we made these refinements until we came up with a tool that gave us what we really needed," Chowaniec says. "Now we are at a point where the tool is not identifying anyone prematurely."
- Educate, train, inform staff: Both LT care staff and hospice staff needed to be educated on the QI process and changes, and there had to be some promotion of the benefits the improvements would provide to patients.
The collaborative team set up formal inservices and workshops, as well as participated in an awareness campaign, Chowaniec says.
The LT care staff incorporated education in the morning meetings, and they let everyone know that the two organizations were entering into a structured collaborative, she adds.
"Then we targeted units that were trained in use of the Flacker tool, and we helped them understand how they would incorporate the tool into their daily routine," Chowaniec says.
Then as the change resulted in measurable improvements, staff was told of the successful outcomes, which helped to facilitate even more buy-in, Chowaniec says.
"We've seen a shift in focus and awareness in the [LTC] building," she notes. "There's a better understanding of residents' decline, and there's a better understanding of what residents' wishes are."
Also, the LT care staff is less likely now to avoid the patient who has been referred to hospice care, Chowaniec says.
LT care staff now will rally around the dying residents and attend their deaths, as well as participate in the end-of-life process in a way they never had before, she says.
"They have found this time shouldn't be a discontinuation of everything, and the staff and faculty have found creative ways to celebrate the individual's life," Chowaniec says.
Hospice physicians initially resisted the change because use of the tool identified LT residents for end-of-life care at a point sooner than what doctors were accustomed to, Chowaniec says.
"It took us out of our comfort zone," she adds. "Here we are in hospice, and we've expressed a desire to promote earlier access, and when we promote an activity that moves us in that direction, we suffered some unease with it."
Marketing of the collaboration and changes continues in some subtle ways, including the ongoing presence of hospice staff in the building, she adds.
- Incorporate QI success into organization's long-term goals: Now that the QI project has evolved for a year, producing positive outcomes, the next step will be to help it grow beyond the pilot project stage, Chowaniec says.
"I believe this project will be readily acceptable by us on the hospice side, and if we can continue to promote it to long-term care, it will easily be incorporated into the natural routine," Chowaniec says.
Reference
1. Kiely DK, Flacker, JM. The Protective Effect of Social Engagement on 1-Year Mortality in a Long-Stay Nursing Home Population. J Clin Epidemiol. 2003;56:472-478.
The Center for Hospice and Palliative Care in Cheektowaga, NY, has a head start on many other hospices in the effort to develop quality improvement projects that will pass muster with the Centers of Medicare and Medicaid Services...You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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