Download Transition Through The Continuum of Care

Transition Through
The Continuum of Care
Hospice and Long-Term Care
Hospice Philosophy
• Hospice is a philosophy of healthcare for
people at the end of life, which seeks not to
prolong life unnaturally, but to ensure that in
the time left to the dying person, his or her life
is as full and comfortable as possible.
• Hospice seeks to enhance the dying person's
quality of life and to provide support for family
and other caregivers.
Goals of Hospice
• The main goal of hospice care is to reduce
potentially unavoidable physical, emotional,
psychosocial, and spiritual suffering
encountered by patients during the dying
process.
• As a result, medical care during this period is
very delicate and needs to be individually
tailored. End-of-life care requires detailed
attention to each person's wishes, beliefs,
values, social situation, and personal
characteristics.
History
• The term “hospice” (from the same linguistic
root as “hospitality”) can be traced back to
medieval times when it referred to a place of
shelter and rest for weary or ill travelers on a
long journey.
• The name was first applied to specialized care
for dying patients by physician Dame Cicely
Saunders, who began her work with the
terminally ill in 1948.
• Create the first modern hospice: St. Christopher’s
Hospice in London.
History
• Saunders introduced the idea of specialized
care for the dying to the United States during a
1963 visit with Yale University.
• Her lecture, given to medical students, nurses, social
workers, and chaplains about the concept of holistic
hospice care.
• Included photos of terminally ill cancer patients and
their families, showing the dramatic differences
before and after the symptom control care.
• This lecture launched the following chain of events,
which resulted in the development of hospice care as
we know it today.
History
• In the United States, hospice was originally run
by volunteers who cared for dying patients. In
the 1980s
• Medicare authorized formal hospice care and
Medicare hospice benefits became part of Medicare
Part A.
• State-run insurances or Medicaid also offer hospice
benefits, as do most private insurances.
Medicare Hospice Benefit
• Covered Services:
• Medicare covers a wide range of services to provide the most
comprehensive care as possible. Your Medicare benefit covers the
following services and pays nearly all of the cost associated with them:
• Physician care
• Nursing care
• Medical supplies (bandages, catheters, diapers, etc.)
• Medical equipment (oxygen machine, wheelchair, hospital bed, etc.)
• Medications for pain and symptom control
• Home health aide services
• Medical social services
• Counseling (spiritual, emotional, dietary)
• Therapists (speech, physical, occupational)
• Short term stays in nursing facilities for respite care
Medicare Benefit
• Length of Coverage
• Once you have been certified for hospice by two physicians, you
are eligible for two 90 day periods of hospice care followed by an
unlimited amount of 60 day periods.
• What this means is, at the beginning of each 90 day or 60 day
term, your doctor will have to re-certify that you still have a
terminal illness.
• If you improve dramatically during hospice care, for example if
your cancer suddenly goes into remission or your terminal illness
gets much better, and your life expectancy increases from 6
months or less, your doctor may “graduate” you from hospice
care.
• This would mean your Medicare benefit is no longer a hospice
benefit and reverts back to standard Medicare Part A.
• You can be readmitted to hospice any time you experience a
decline and two doctors certify you have a terminal illness with a
life expectancy of 6 months or less
Complex Care
• The complex care of hospice patients may include the following:
• Managing evolving medical issues (infections, medication management,
pressure ulcers, hydration, nutrition, physical stages of dying)
• Treating physical symptoms (pain, shortness of breath, anxiety, nausea,
vomiting, constipation, confusion, etc.)
• Counseling about the anxiety, uncertainty, grief, and fear associated with
end of life and dying
• Rendering support to the patient, their families, and caregivers with the
overwhelming physical and psychological stresses of a terminal illness
• Guiding patients and families through the difficult interpersonal and
psychosocial issues and helping them with finding closure
• Paying attention to personal, religious, spiritual, and cultural values
• Assisting patients and families reaching financial closures (living will, trust,
advance directive, funeral arrangements)
• Providing bereavement counseling to the mourning loved ones after the
death of the patient
4 Various Level Of Care
•
Routine Home Care-This is the most common level of hospice care. Routine home care
includes, but is not limited to, nursing and home health aide services. Patients may
receive Routine Hospice Care in their home or what they “call home”—in a long-term
care or assisted living facility.
•
General Inpatient- is care for pain control and symptom management that cannot
effectively be provided in other settings. It is usually of a short-term nature and can be
provided in a hospital, hospice unit or long-term care facility. Compassionate Care
Hospice has dedicated inpatient hospice units in some of our programs.
•
Continuous Home Care- is provided during periods of crisis in which a patient requires
continuous nursing care to achieve palliation or management of acute medical
symptoms. This intensive care is provided in the patient’s home or facility where they
live. In addition to being visited by the team members, the patient will receive up to 24
hours a day care by a licensed nurse and hospice aide, when on Continuous Home Care.
•
Respite Care- short-term inpatient care provided to the patient when necessary for the
purpose of providing a break in care giving to the patient’s caregiver(s). It is only
provided on an occasional basis, for a maximum of five days approximately every 90
days. Respite Care is provided in a hospital, hospice unit or long-term care facility.
Interdisciplinary Team
• Occupational therapists and other therapy
services
• Speech therapists
• Home health aides
• Volunteers
• Nurses
• Social Workers
Interdisciplinary Team
• Social Workers:
• work closely with patients, families and caregivers
to create and maintain a supportive care setting.
• They are available to help patients and families deal
with personal, financial, emotional and care planning
issues that arise. The social worker may:
• Identify community resources and provide referrals.
• Help with confusing paperwork for assistance
programs and insurance.
• Help with the emotional side of the dying process.
Interdisciplinary Team
• Social Workers:
• work closely with patients, families and caregivers
to create and maintain a supportive care setting.
• They are available to help patients and families deal
with personal, financial, emotional and care planning
issues that arise. The social worker may:
• Identify community resources and provide referrals.
• Help with confusing paperwork for assistance
programs and insurance.
• Help with the emotional side of the dying process.
Interdisciplinary Team
• Social Workers:
• Assistance with funeral planning.
• Identifying emotional and spiritual needs of the patient and their loved
ones and finding appropriate support as needed.
• Assistance with bridging family gaps to bring loved ones together
whenever possible (for example, help obtaining temporary Visa's for
out-of-country family members).
• Assisting survivors with necessary arrangements and paperwork after
death occurs.
• Assisting survivors in obtaining appropriate grief counseling.
• Identifying other needs of the patient and their support circle and
assisting as needed.
• Advance Care Planning
Myths
• Hospice Care Means Giving Up Hope
• Hospice Is Only for Cancer Patients
• Hospice Is Only for Patients who Are Close to
Death or Actively Dying
• Hospice Means That I Have To Sign a DNR
Settings
• Home
• Assisted Livings
• Long Term Care Facilities
THE ROLE OF THE SOCIAL
WORKER IN THE LONG TERM
CARE SETTING
ISU SOCIAL WORK DAY
MARCH 19, 2014
APOSTOLIC CHRISTIAN RESTMOR
• LONG TERM CARE
• RESTMOR
• MY ROLE
The Role of the Social Worker
• RESIDENT
• FAMILY
• ACR TEAM MEMBER
• REGULATORY AGENCIES
The Resident
• PRE-ADMISSION ASSESSMENTS
• PROMOTES & PROTECTS RESIDENT
RIGHTS
• CARE PLANNING
• GRIEVANCES
• COORDINATES APPOINTMENTS
THE FAMILY
• COORDINATES FAMILY
MEETINGS
• CARE PLAN MEETINGS
WITH FAMILY
• LONG DISTANCE FAMILY
BRIDGE
THE TEAM
• ABUSE OFFICER
• SECURITY COUNCIL
• ADMINISTRATIVE STAFF
• QUALITY ASSURANCEPERFORMANCE IMPROVEMENT
TEAM
• NEW EMPLOYEE
ORIENTATION FACILITATOR
REGULATIONS
• RESIDENT RIGHTS
• HIPAA
• ABUSE INVESTIGATION
AND REPORTING
WHY LTC? WHY NOT?
• SOCIAL WORKER-RESIDENT
RELATIONSHIP
• VITAL TEAM MEMBER
• POTENTIAL LONG TERM
EMPLOYMENT
• VARIETY & CONSISTENCY
LTC SOCIAL WORKER
• PASSIONATE AS AN
ADVOCATE FOR THE
ELDERLY
• FLEXIBLE TIME MANAGER
• EXCITING ROUTINES
References
• NHPCO (National Hospice and Palliative Care
Organization) (nhcpo.org).
• Medicare (medicare.gov).
• Apostolic Christian Restmor - Mission
Statement; Social Work Job Description,
Facility brocure