Evercare Quality Improvement Awards James Collins M D

Evercare Quality Improvement Awards James Collins, M. D. Julie Hayes, R. N. Randy Muenzner

Faculty Disclosures: Dr. Collins Medical Director, Evercare Pfizer Pharmaceuticals: Speakers Bureau Eisai Pharmaceuticals: Speakers Bureau

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

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

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.

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 resident’s status, advanced directives and options for treatment.

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.

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.

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.

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 didn’t look like the type of End of Life Resident with whom staff were familiar.

Tools Used to Affect Change • Tools used – Information obtained from last MDS completed. – Assessment schedule follows MDS cycle. • Tools created – Modified Flacker Form

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.

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.

Outcomes • Improved Quality of Service – Priority is determined by the resident’s 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.

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 Staff’s “every day” routine work – Created a culture within the building to allow for all involved to be comfortable with the dying process.

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.

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

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?