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NURSING HOME PALLIATIVE CARE TOOLKIT - …

NURSING home . PALLIATIVE care . TOOLKIT . Originally Developed September 2013, Revised June 2014. This material was prepared by Healthcentric Advisors, the Quality Improvement Organization Support Center for rhode Island, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the Department of Health and Human Services. Publication #10 SoW-RI-GEN-102013-927. NURSING home PALLIATIVE care Steering Committee Members Healthcentric Advisors Name Position Debra Anderson Executive Assistant Richard Besdine, MD Senior Director, Medical Affairs Sheryl Leary, LSW Program Coordinator Melissa Miranda Senior Program Administrator Lynn McNicoll, MD Geriatrician, Chief Clinical Consultant Blake Morphis, BS, CPEHR Senior Health Information

7 Background Launched in August 2013, the Nursing Home Palliative Care Collaborative of Rhode Island was a partnership between Healthcentric Advisors, the Quality Improvement Organization

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Transcription of NURSING HOME PALLIATIVE CARE TOOLKIT - …

1 NURSING home . PALLIATIVE care . TOOLKIT . Originally Developed September 2013, Revised June 2014. This material was prepared by Healthcentric Advisors, the Quality Improvement Organization Support Center for rhode Island, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the Department of Health and Human Services. Publication #10 SoW-RI-GEN-102013-927. NURSING home PALLIATIVE care Steering Committee Members Healthcentric Advisors Name Position Debra Anderson Executive Assistant Richard Besdine, MD Senior Director, Medical Affairs Sheryl Leary, LSW Program Coordinator Melissa Miranda Senior Program Administrator Lynn McNicoll, MD Geriatrician, Chief Clinical Consultant Blake Morphis, BS, CPEHR Senior Health Information Analyst Nelia Odom, RN, BSN, MBA/MHA Senior Program Coordinator Gail Patry, RN, CPEHR Senior Director.

2 Quality Improvement Programs NURSING home PALLIATIVE care Steering Committee Members Name Organization Affiliation Pam Bibeault, RNC, MS, NHA, CLNC Triad Health care , LLC. Diane Blier, ANP Beacon Hospice an Amedisys Company Michele Branagan Gentiva Hospice (Formerly Odyssey Hospice). Virginia Burke, Esq RI Health care Association Rev. Marie Carpenter The RI State Council of Churches Jennifer Cellar, NP Evergreen House Health Center Patricia Chace, MD, CMD OPTUM / CarePlus John E. Gage, MBA Health Concepts, Ltd.

3 Kathleen Heren Alliance for Better Long Term care Kate Lally, MD, FACP care New England Kent Hospital Susan Miller, PHD, MBA Brown University Karen Morin Health Concepts, Ltd. & RI Health care Association James Nyberg Leading Age RI. Adele Renzulli Department of Health Therese Rochon, RNP, MA, MSN care New England Mary Jean Sylvaria, RN Saint Elizabeth Manor and Leading Age RI. Shirley Thomas Hopkins Manor We welcome the opportunity to respond to your questions as they relate to this TOOLKIT and the NURSING home PALLIATIVE care Collaborative.

4 If you would like further information, please contact Healthcentric Advisors at 401-528-3200. 1. 1 Contents 1 INTRODUCTION .. 6. Background .. 7. Overview: PALLIATIVE care in NURSING Homes .. 8. 2 GENERAL PALLIATIVE care RESOURCES .. 10. PALLIATIVE care Preferred Practices .. 11. On-Line Resource Links .. 14. Publications List for Further Research .. 17. 3 GENERAL TEAM RESOURCES .. 22. NURSING home PALLIATIVE care Team Contact List .. 23. NURSING home PALLIATIVE care One Year Work Plan .. 24. PALLIATIVE care Team Meeting Agenda Template.

5 28. 4 DATA COLLECTION AND MANAGEMENT .. 29. PALLIATIVE care Practices: Measurement Guidelines and Tools .. 30. PALLIATIVE care Measures Data Collection Tool .. 35. PALLIATIVE care Measurement Calculations .. 39. PALLIATIVE care Data Entry .. 40. 5 QUALITY IMPROVEMENT & CULTURE CHANGE .. 44. Overview of Change Methods .. 45. HATCh Model to Support Transformational 46. Domain 1: Workplace Practice .. 46. Domain 2: Environment .. 47. Domain 3: care 48. Domain 4: Leadership 48. Domain 5: Family/Community 49.

6 Domain 6: Regulatory/Government .. 49. Root Cause Analysis .. 49. Making the Change: .. 54. PALLIATIVE care Best Practice AIM Worksheet (Template) .. 55. PALLIATIVE care Best Practice AIM Worksheet (Sample) .. 56. PSDA Worksheet (Template) .. 57. PDSA Worksheet (Sample) .. 58. 2. Knowledge, Skills and Attitude (KSA) .. 60. Competency 60. Change Idea Sheets .. 65. Change Idea Sheet: Proxy Decision-Makers and Advance care Planning .. 65. Change Idea Sheet: Completing a Pain Assessment in NURSING Homes .. 71.

7 Change Idea Sheet: Having Discussions with Residents Regarding Prognosis and Goals of care .. 77. Change Idea Sheet: Spiritual care for NURSING home Residents .. 84. Sharing Results .. 89. Storytelling: Answer these questions to develop your facility's improvement story .. 90. Patient/Resident Storytelling .. 90. 6 INTERVENTION TOOLS .. 91. Staff Assessment Tools .. 92. Interdisciplinary Team Competency Grid .. 92. Physician's Brief .. 93. The Educational Needs Assessment Tool .. 94. PALLIATIVE care Screening Tools.

8 97. Use of the MDS Section V: care Assessment Summary .. 97. Flacker Mortality Scale .. 97. Karnofsky Performance Scale Index .. 100. PALLIATIVE care Consult Services Screening Tool .. 101. General Questionnaire .. 102. General PALLIATIVE care Education .. 102. Resident-Family Communication Tools .. 103. Fast Facts for Clinicians .. 103. Pocket Guides for 104. Prognosis Discussion Tool .. 109. The Family Goal Setting Conference (Pocket Guide) .. 110. The PALLIATIVE Response Full Text and Pocket Guides.

9 111. Resident and Family Communication Summary (Sample) .. 112. Family Conference Checklist* .. 113. Spiritual care Tools .. 114. 3. SPIRITUAL care ASSESSMENT (Sample) .. 114. Why Call A Chaplain? (Provided by rhode Island Hospital Chaplains) .. 115. Resources for Developing/Improving a Chaplain Program in Long Term care .. 116. Evaluating Your Spiritual care Assessment Process .. 116. Spiritual Assessment .. 116. Article Authored by the Joint Commission .. 117. Hope Spiritual Assessment 117. FICA Spiritual Assessment Tool.

10 117. Fast Facts for Clinicians .. 118. Promoting Excellence in End-of-Life care .. 120. Assessing Staff Beliefs Regarding Spiritual care .. 120. Pain Assessment Tool .. 121. Use of the MDS RAI .. 121. The Wong-Baker FACES Pain Rating Scale .. 122. The FLACC Scale .. 122. University of Pennsylvania School of NURSING Pain Assessment Tool (Copyright Genesis Health care ) .. 122. Chart of Non-Pharmacological Interventions for Physical, Spiritual and Psychological Pain . 122. In-ServiceTraining to Understand Pain.