PATIENT GOAL ORIENTED IDT MEETINGS: A MODEL TO IDENTIFY, PLAN, AND MEET PATIENT GOALS ACROSS HOSPICE DISCIPLINES

Lynn Kefgen, RN, BSN, CHPN

Clinical Manager

Stacey Jones, MSW, LASW

Clinical Manager

Providence Hospice of Seattle

Reflection

OB

JEC

TIV

ES

Understand the philosophy of a patient/family goal oriented IDT meeting and how this will benefit the outcomes of patient/family care.

Explore how to develop goals and interventions to meet patient and family goals in the IDT meeting for good outcomes.

Describe how each discipline can contribute to care planning.

Define the concept of “plan of care” Review Conditions of Participation Identify documentation practices

and tools that lead to goal identification, interventions and outcomes.

Explore how patients who have died touch us and teach us.

HISTORY

o Poor team collaborationo Medically Orientedo Focus on clinician goalso Medicare Regulations not being

meto Confusion about what “plan of

care” meanso Every IDT was run differentlyo Inefficient

2012

GOALS To create an environment that is conducive to

team participation and collaboration. To focus on what is important to patient and

family as they are the ones that will guide their end of life experience.

To instruct clinicians on meaning of “plan of care”

To align IDT meetings with the requirements outlined in the Medicare Conditions of Participation (COPs).

To standardize IDT meetings and make them consistent among all teams.

To make IDT meetings more efficient.

CONDITIONS OF PARTICIPATION

CONDITIONS OF PARTICIPATION (COPS) Medicare Conditions of Participation

(CoPs) for hospice care have been in existence since 1983, with the establishment of the Medicare Hospice Benefit.

These Rules govern all Medicare-certified hospices.

CoPs are revised periodically.

WHAT IS THE PURPOSE OF IDT?* To develop an interdisciplinary “plan of care”

(POC) that meets the evolving needs and goals expressed by the patient and/or family and reviews the progress towards these desired outcomes.

To review, revise and document this POC as patient’s condition requires but no less frequently than every 15 calendar days.

To coordinate services and show how all services are working to meet goals.

Mandatory attendees - RN, MSW, CH and MD.

* CoP: 418.56 Interdisciplinary group, care planning, and coordination of services

INTERDISCIPLINARY TEAM

PLAN OF CARE

COMPONENTS OF A PLAN OF CARE (POC)

Interventions to manage pain/other symptoms and achieve goals.

Scope (who) and frequency of services necessary to meet the specific patient and family needs and goals (AFD orders).

Anticipated measurable outcomes. Drugs and treatments. Medical supplies and appliances. Documentation of patient/caregiver’s level of

understanding, involvement, and agreement with plan of care.

* CoP: 418.56 Interdisciplinary group, care planning, and coordination of services

PURPOSE OF A PLAN OF CARE (POC)?

o Outlines patient and family goals.o Outlines interventions that will be

implemented to resolve or support the goals identified by each discipline’s assessment.

o Describes outcomes (results) based on interventions.

o Provides a ‘road map’ to guide all who are involved in care.

o Must be individualized and reflect patient and family goals and meet their needs.

o Must be reviewed and update every 15 days (minimum).

GOALS

WHAT ARE GOALS?A goal is a desired result or outcome that a person or a family envisions, plans, and commits to achieve.

Goals are WishesConcernsHopesNeeds

HOW TO ELICIT GOALS?

What do you think is most important to you and your family right now?

What are your needs at this time?

What are your concerns now and/or for the future?

What experiences do you want have now and/or in your future?

What would you still like to accomplish?

What do you wish you could still do?

What is important for you to have control over?

What are things that bring you joy and comfort?

What are the most important relationships in your life?

Is there anyone you would like to see, talk to or visit with?

What are you hopeful for?

What contributes to a sense of meaning and purpose?

HOW TO ELICIT GOALS?

Are you uncomfortable because of pain (or other symptom)?

What would be an acceptable level of pain (or control) for you on a scale of 0-10?

What has controlled your pain (or other symptom) in the past? Would you be willing to try something new?

Having physical symptoms controlled is a goal

IMPLICIT GOALS

Goals can be developed not only based on words spoken by patient but also based on changes in behavior, facial expressions, and mood

Goals are desired experiences

Example: Patient has asked TV

to be turned down & turned away visitors.

Patient desires quieter environment with less visitors.

Goals can be implied

SOURCES OF GOALS Patient stated … Family member

related patient likes to …

Caregivers voiced patient used to enjoy…

Patient would like to continue …

Patient and family hopes to be able to …

Family wishes to ... Patient wants to …. 5 Wishes/Living will

declares …

Patient has always wanted to…..

Patient requested … When discussing …

patient related…desire to…

Caregivers voiced the hope …

Caregivers hope to be more confident in…

Caregiver would benefit from…

Recent change in condition results in new goal of …

IDT MEETING

WHAT IS THE FOCUS OF IDT MEETINGS?

IDT will name patient and family goals. IDT will plan how each discipline and the

team as a whole will support patient and family in meeting their goals and achieve good outcomes in the following two weeks.

IDT will report how each discipline and the team as a whole has supported patient and family in meeting their goals in the past two weeks (outcomes).

IDT will document these goals, interventions, and outcomes in an IDT note.

IDT EXPECTATIONS - CLINICIAN Be on time Know cases and review if needed prior to IDT Be prepared to contribute to the IDT

discussion All team members will contribute to

discussion Actively listen to other team members Remember all team members are equal in

the discussion. Discuss patient/family using non judgmental

language

IDT EXPECTATIONS – MANAGERS Before care planning time begins, manager

will have all information that clinicians need for the meeting.

Start and end meeting on time. Keep meeting on track. Keep the focus of the meeting on discuss of

patient/family goals, interventions and outcomes.

Include discuss eligibility as indicated. Ensure that all new employees are trained on

the IDG process.

OUR MODEL

COMPONENTS OF THE IDT

Care Planning Time

Conditions of Participation (CoP) Time

Legacy Time

CARE PLANNING TIME

Make the discussion patient and family centered

Focus on care planning: Discuss

patient/family goals Develop

interventions that will help patient and family to meet their goals

Review what has been accomplished

Discuss patients in this order: Admissions Re-certifications All others

Write IDT notes during discussion

Group includes RN, MSW, CH, HA.

Most Important Ideas

CARE PLANNING TIME Determine facilitator, time keeper and

process checker. Determine who will write what notes. Eliminate extraneous discussion not

pertinent to meeting patient and family goals.

Eliminate stories and anecdotes not relevant to care planning.

Identify patients that need more discussion during CoPs time.

CONDITIONS OF PARTICIPATION TIME

Person who has written the IDT note will present the patient

Present patient information and goals succinctly, allowing time for discussion where needed

Utilize full team for consultation

Ask questions that small team could not answer

Finalize written plan of care for each patient

Group includes MD, RN, MSW, CH, HA, OT, VOL, GSS, Pharmacist

Most Important Ideas

CONDITIONS OF PARTICIPATION TIME

Order of Presentation: Admissions Re-certifications Possible Live Discharges Challenges

LEGACY TIME

Memorialize patients who have died Share experience of caring for our patients

and families Discuss what has been learned from our

experience

Most Important Ideas

LEGACY TIME Chaplain is leader. Names of patients who have died in last two

weeks are written for viewing Legacy time consists of:

Reflection Reading of the names of patients who have

died in the last 2 weeks Memorialization of patients

Questions to provoke conversation: What stories would you like to share about

patient/family? What have you learned from caring for patient? What will you take away from your experience

with patient/family?

IDT FLOW

8:15 – 9:25 Care Planning 9:25 – 10:05

Group 1 Care Planning Group 2 CoPs

10:05 – 10:45 Group 1 CoPs Group 2 Care Planning

10:45 – 11:05 Legacy

Example

EX

AM

PLE

DOCUMENTATION

IDT NOTE TEMPLATE Patient/family goals/wishes/concerns/needs:

Outcomes and updates to current plan of care (what are the outcomes of your last interventions and what will you do next?):

RN: MSW: CH: HA: OT:

Patient and family plan of care reviewed and developed with RN, MSW, CH, MD, HA, OT, manager, pharmacist, volunteer services, and grief support services:

EXAMPLE IDT NOTE (1) Patient/family goals/wishes/concerns/needs:

Family wants pt to go to activities as she is able Family would like pt to receive personal care and be dressed nicely Family want help instructing staff to give pain meds Family would like help to apply for Medicaid

Outcomes and updates to current plan of care (what are the outcomes of your last interventions and what will you do next?):

RN: Educate staff on importance of using pain meds and signs of when to use.

MSW: Assist family with Medicaid process. Provide social stimulation by taking pt to activities. Encourage staff to take pt to activities.

CH: Will contact family to determine care plan for chaplain services. HA: Orders for aide for personal care written for2x/week. Aide will

contact family to discuss personal care preferences

Patient and family plan of care reviewed and developed with Lynn Kefgen RN, Stacey Jones MSW, June Evans CH, Tom Smith MD, Spring Wicks HA, Marla Olson OT, Stephanie Mills Manager, Kristen Egan pharmacist, Kelly Katz VOL, Ross Riley GSS.

EXAMPLE IDT NOTE (2) Patient/family goals/wishes/concerns/needs:

Pt would like to continue to teach students to prepare for last recital Pt wants bed and home set up to minimize energy spent and conserve energy

for teaching Pt would like to schedule pain meds to allow for alertness during teaching

  Outcomes and updates to current plan of care (what are the outcomes of

your last interventions and what will you do next?):

RN: Current morphine dose successful in keeping pain at desired level of 2. RN to work with MD and pt to create a pain regimen with ranges that allows for max alertness and least amount of pain on teaching days.

MSW: Educate and encourage patient/family on how to limit visits and structure day to conserve energy.

CH: Provide active listening related to patients stated love of teaching, and students

HA: Personal care 2/wk on non-teaching days OT: Bed, WC, and commode set up on main level of house. WC fits in the

piano room.

Patient and family plan of care reviewed and developed with Lynn Kefgen RN, Stacey Jones MSW, June Evans CH, Tom Smith MD, Spring Wicks HA, Marla Olson OT, Stephanie Mills Manager, Kristen Egan pharmacist, Kelly Katz VOL, Ross Riley GSS.

EXAMPLE IDT NOTE (3) Patient/family goals/wishes/concerns/needs:

Pt would like pain less than 3 and be nausea free Husband wants to have EOL conversations and know what to expect as

pt declines Pt and husband enjoy sharing stories of their life

Outcomes and updates to current care plan of care (what are the outcomes of your last interventions and what will you do next?):

TEAM: Will facilitate EOL conversations with husband and assist him in knowing what to expect.

RN: Recent increases in morphine have decreased pt’s pain level to 3. Pt/husband know to call RN if pain meds no longer effective. RN to assess effectiveness of nausea meds at next visit.

MSW: Husband now has hired cg at night and reports better ability to cope.

CH: Continue to provide active listening related to pt and husband’s sharing of life stories and meaning.

Patient and family plan of care reviewed and developed with Lynn Kefgen RN, Stacey Jones MSW, June Evans CH, Tom Smith MD, Spring Wicks HA, Marla Olson OT, Stephanie Mills Manager, Kristen Egan pharmacist, Kelly Katz VOL, Ross Riley GSS.

REFERENCES Federal Register

http://www.ecfr.gov/cgi-bin/text-idx?rgn=div5&node=42:3.0.1.1.5

NHPCO http://

www.nhpco.org/hospice-operations/cfr-418-subpart

Demiris G, Washington K, Parker Oliver D, Wittenberg-Lyles E. A study of information flow in hospice interdisciplinary team meetings. J Interprof Care. 2008 December; 22(6): 621-629.

Workshop: Transforming your Interdisciplinary Group; May 19-20, 2011; Suncoast Institute

QU

ES

TIO

NS

?