Impact of Advanced Illness Management Program

Impact of Advanced Illness Management Program

Table shows the increase in patients that were discussed in case conferencing, percent of VNA patients with and advance directive since the start of education and training, number of home visits made by the nurse practitioner from 2013 to 2016. The hospice census and referrals from a community source more than doubled.

Impact of Advanced Illness Management Program on Hospice since 2013

Increase in the percent of hospice referrals that come from community referrals versus hospital referrals. This is significant because community referrals represent a longer length of stay allowing the patient to receive quality hospice care in the last months of life.

Hospice length of stay for patients referred from the community ( Red) is almost double that for the patients that are referred from the hospital (Blue). The mean length of stay for the patients referred from the community shows that these patients remain out of the hospital and at home for the last 30 to 60 days of life but those that did not get referred to hospice sooner are hospitalized in the final month of life and then referred to hospice for a mean length of stay on hospice of 5 to 6 days.

The home health agencies ranking on the percent who rated the agency with the highest rank increased from 58.2% in 2014 to 62.1% in 2016. The percent who would recommend the agency went from a national ranking of 51.15 percentile in 2014 to 73.9 percentile in 2016 (Home Health Compare.gov 2016).

Improvement in managing pain increased from 37.3 percentile in 2014 to 47.5 percentile in 2016. A 60 - day Emergency Department use without Hospitalization declined resulting in improved CMS national rating of 42% in 2014 to 61.3% in 2016. The 60 - day Hospitalization rating improved from 38.7 percentile in 2014 to 42.1 percentile in 2016. Satisfaction measures based on Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) showed improvement in the three year period.

Advanced Illness Case Conference SBAR Template

SITUATION

Age

Diagnosis (including the chronic advance illness)

BACKGROUND

State the pertinent medical history

Reason for recent hospitalizations

Why is the patient on homecare

Assessment

Give a brief synopsis of the treatment and effectiveness including the areas listed below:

Physical Issues

Psychological Issues

Social Issues

Spiritual Issues

Practical Issues

Weight Loss

Functional Status

Any changes from prior assessments

Advance Directives:

Has the discussion occurred?

Is there a DPOA?

Is the patient/family realistic in their expectations?

RECOMMENDATIONS:

This will be filled out by the leader after the case conference discussion

References:

Home Health Chartbook 2015: Prepared for the Alliance for Home Health Quality and Innovation. October 2015. avalere.com.

Lally, K, Rochon, T, Roberts, N, McCutcheon, K. The Conversation Nurse Model: An innovation to increase palliative care capacity. Journal of Hospice & Palliative Nursing. 2016, 18 (6) 556-63.

Lustbader, D, Mudra, M, Romano C, Lukoski, E, Cooper, D, et al. The Impact of a Home-Based Palliative Care Program in an Accountable Care Organization Journal of Palliative Medicine 2017; 20 (1) 23-28.

Resnick, H, Hickman, S, Foster, G. Documentation of Advance Directives among Home Care and Hospice Patients in the United States, 2007. American Journal of Hospice and Palliative Medicine 2012, 29 (1) 26-35.

VNAA vulnerable Patient Study, Rosati,R, Sheehan,K, and Russell, D. Presentation for the 2013 NAHC Annual Meeting. Gaylord National Resort, October 31–November 3, 2013