Kasey Stevens | Quality Insights: All righty. Now that it's 11, we're gonna go ahead and get started. I know folks are gonna continue to filter in as we get rolling this morning. But hello! And welcome to today's webinar. My name our webinar this morning is palliative care versus hospice care. What's the difference. My name is Casey Stevens, and I'm a communication specialist at quality insights in your host for today's presentation. We get started in just a few moments. But first couple of housekeeping items I want to keep in mind today
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Kasey Stevens | Quality Insights: and the end of today's program. You'll be asked to complete a short evaluation.
Kasey Stevens | Quality Insights: helping us kind of evaluate what we did well in the program, and how we can improve and then land in if you don't care to advance that next slide, please.
Kasey Stevens | Quality Insights: So today's webinar will be eligible for free nursing physician and nursing Home Administrator. Continuing education credits. You can see the expiration dates here. If you're interested in obtaining credit, you need to stay for the entire 45 min webinar and complete an evaluation and knowledge check.
Kasey Stevens | Quality Insights: Sorry I'd like to. It is a full hour, webinar.
Kasey Stevens | Quality Insights: and then complete the evaluation and knowledge check. We will share the link to that. That evaluation at the end of today's discussion. Leave in the next slide, please.
Kasey Stevens | Quality Insights: So here are the details on continuing education credits for physicians, nurses, and nursing home administrators.
Kasey Stevens | Quality Insights: The next slide, please.
Kasey Stevens | Quality Insights: Right? We're learning outcomes for this course include describing the purpose of both palliative and Hospice care if we to be able to differentiate the services provided under palliative and Hospice care, identify different settings that are appropriate for palliative and hospice care, and to be able to see 2 barriers of referrals to Paladin or Hospice care.
Kasey Stevens | Quality Insights: Today's presenter is land in Lincolnshire.
Kasey Stevens | Quality Insights: Lanham, Lincolnshire is the chief nursing officer with Hospice of Southern West Virginia, he received his associate of Science and Nursing, and his Bachelor of Science, and Nursing from Bluefield State University, and his master's in Nursing education and postgraduate certificate as a family nurse, practitioner from Marshall University.
Kasey Stevens | Quality Insights: He's a former assistant professor of nursing for Bluefield State University for Raja, professor for Mountain State University, and a 2,017 recipient of West Virginia future of nursing 40 under 40 emerging Nurse Lear award. He's a certified hospice and pallet of careers with almost 15 years of service with hospice and palliative care. Landon, thank you so much for joining us today, and I'll let you take over from me.
Landon Blankenship: Okay, thank you so much, Casey.
Landon Blankenship: So just to get started. The first thing I want to say is is how important I think it is to distinguish between the differences of between hospice and palliative care.
Landon Blankenship: unfortunately, way back in the early days of Hospice care, I think the terms Hospice and palliative was used kind of interchangeably. So if if someone was mentioning palliative care naturally, that could also mean hospice care, and I think that's unfortunately, where a lot of us are
Landon Blankenship: today. is that we? We still see us hospice and pallet of being one of the same. So hopefully we can differentiate that some today and help everyone to to understand the
Landon Blankenship: the difference is in those 2. So
Landon Blankenship: just briefly, we're going to hit on some definitions. A serious illness, of course, is a health condition that carries a risk, a high risk
Landon Blankenship: of mortality. or excessively strains their caregivers. And basically that's going to have a big impact on a person's daily function on their quality of life, which we will talk about a little bit more in just a few minutes.
Landon Blankenship: Differences between palliative care and hospice care. Palliative care is a Ha. Has patients who have a high risk of mortality.
Landon Blankenship: but they're not necessarily terminally ill now, but not necessarily. That means that the the palliative care, patient, as we will see later on, does not have to have a terminal diagnosis
Landon Blankenship: or a terminal prognosis. However, there are a lot of palliative care patients who who does not want to go with Hospice care. So there. There may be patients in palliative care depending on the programs set up that may actually still take care of terminally ill patients.
Landon Blankenship: whereas
Landon Blankenship: hospice care primarily focuses on caring, not curing so palliative care. We're seeing them a lot farther upstream in their disease process via a serious or chronic illness, whereas Hospice care. We're really not focused on cure. We're primarily focused on
Landon Blankenship: making the patient comfortable.
Landon Blankenship: So this is where we are for many, many years in health care. You had door A and door B. So if I was a patient and went in today and had a got a diagnosis of congestive heart failure. I had 2 options to take. I could take door A, which meant that I was going to seek aggressive treatment
Landon Blankenship: and get all the treatment that I wanted to try to. Maybe even though we know there's not a cure for chronic illnesses, maybe try to find the best solution possible, or close the as close to the cure as what I could possibly get, or it was Door B. And or B. Said, Well, you know you have this serious chronic illness.
Landon Blankenship: you know. You probably just need to go some way or go with a hospice organization. Make yourself comfortable. all the way to the end of life, because, you know, you're not getting aggressive treatment. So that was kind of the 2 options that we had for many, many years. There was. Either you go the aggressive treatment route or you go the Comfort Route.
Landon Blankenship: But thankfully, over time. We've really discovered that there there really needs to be a a door, see? And that is another option for patients who wants both aggressive treatment, but yet want their symptoms managed and want to be comfortable during their chronic illness. So palliative care is kind of that door seeing it. It's kind of the the
Landon Blankenship: the the gap between seeking regressive treatment and getting curative curative seeking aggressive treatment or getting comfort. Care so pilot of says, Hey, yes, you can get your your comfort. You can get your aggressive treatment. You can get your chemotherapy and get your radiation. You can get all that.
Landon Blankenship: We're going to keep your symptoms controlled. We're going to make sure that your symptoms are managed. all the way up, of course, until the time comes that that you want to do just comfort, care alone.
Landon Blankenship: So it's been a big, a big help to a lot of people.
Landon Blankenship: So panic there is a board certified medical specialty, and it has been since 2,006 once again, it's a specialized form of medicine that treats patients with serious or chronic illnesses. with the ultimate goal of improving patients quality of life. That's the that's the big thing with palliative and hospice is improving patients. Quality of life. So models of of the clinic may vary and that depends on
Landon Blankenship: each program kind of looks at a needs based, or does kind of a needs assessment to see what the community may need or how they may better, you know, function to meet their the the patients in their geographic location to meet their needs.
Landon Blankenship: But many palliative care programs have either a primary clinic
Landon Blankenship: The vast majority of palladic care programs have actual home based care. where they're going into the patients homes and seeing the patients there and then there's a lot of a lot of pile of care programs actually do hospital consults. And some, actually, you know, may even go into the hospitals and and see the patients who have been emitted there.
Landon Blankenship: Visit structure visits is based on need. Now I say this because probably the majority of people.
Landon Blankenship: Majority of people knows Hospice and they new Hospice fairly well, because it's been around so long. So what you get is when people call, they expect
Landon Blankenship: call for a palliative referral. They expect the same types of services as you would get with Hospice, and those 2 things are totally separate their goals are the same to keep. Give in creeps improve patients. Quality of life. But the 2 programs actually are are really, there's lots of similarities. But the differences are major. So the business structure with palliative care is that that the visits are based on need. So
Landon Blankenship: we may go in and see a patient in palliative care. See that patient once every 2 to 3 weeks, then we get their symptoms, manage to their primary care provider, get their symptoms managed, and then eventually we may be able to go to seeing that patient once every 3 months. So it really depends on what's going on with the patient and what they're You know what their needs are.
Landon Blankenship: The medical delivery model, of course, most palliative care programs. I think all palliative care programs have a medical director.
Landon Blankenship: The vast majority of programs actually have family nurse practitioners that work in those. some have physicians assistance. I think the vast majority of the carers provided by physician or a nurse practitioner with some utilizing a physician's assistance. Now, in addition to this, social work plays a big part in seeing patients
Landon Blankenship: at with palliative care. So there are lots of social work needs. So we usually will utilize a social work as well, and then we'll get into a little bit looking at holistic care, and chaplains also play a big part in that to meet the patients needs at at this difficult time in their lives. So who qualifies for palliative care?
Landon Blankenship: Number one. The biggest thing is individuals diagnosed with a life-threatening illness. Now, once again, those are those chronic illnesses that we know there's no cure for your Chf patients, your Co. Pd patients patients with, maybe cancer stage 4 cancer in state, dream or disease. And of course you can see here on the slide, the list goes on. These are all
Landon Blankenship: a very much appropriate patients. who would seek or need to receive palliative care services again. We're looking at patients
Landon Blankenship: farther upstream. not terminally ill at this point in time.
Landon Blankenship: so the big question would be, the end is, why should someone go with palliative care? And I like the aspect that
Landon Blankenship: excuse me.
Landon Blankenship: Palliative care. Treat the person as a whole person. Many times people would think of Palladic care, or even hospice care is really looking at that patient and treating that patient physic or meeting that patient's physical needs. whatever you know. Maybe the the situation, as far as pain, shortness, or breath, making sure that those are managed.
Landon Blankenship: But I really like the fact that it is true holistic care. We're also looking at not only the physical aspect of that patient, but we're also looking at the spiritual aspect of that patient or the psychosocial aspect of that patient to make sure that all of those different aspects of that patients live
Landon Blankenship: our intact. because to make sure that we have the best outcomes, we know that each aspect of that person really has to be intact and really has to be at the optimal level that they may have at that time. So we really try to focus on treating that person as a whole with the primary goal of improving or promoting that patient's quality of life. Once again, that is the number one that the number one reason why these programs exist is because when once patients
Landon Blankenship: well space, it gets a terminal. I mean a a serious or chronic deal on this long before they get terminal. You have to think there's a lot that come with that, so they may get diabetes. And then, the next thing you know, they have hard issues. And then, years later, they have kidney issues. So once they get all of these different, once they get seemingly one serious or chronic illness. Eventually, that's kind of cascades into more things, and we all know that to be true.
Landon Blankenship: is eventually there's there's more there than what they can manage. So, having someone come in supporting the family, adding an extra layer of support for not only the patient and their family, but also the primary care provider of that patient to help manage all of these different aspects of this serious or chronic illness is the big reason why palliative care is so important.
Landon Blankenship: So once again, and not to be repetitive. But the goals of palliative care is naturally improve the quality of life.
Landon Blankenship: another one, too, is to help the patient and family understand all the aspects of the patient's illness. nothing against, you know, doctors, visits, or office visits, or anything like that. But we know that a lot of times in the clinic setting. It is difficult for providers
Landon Blankenship: to take that extra time to sit down and really discuss this patient's illness, like what to expect. You know I'm big on anticipatory guidance, and what may happen, and what do we do if this does happen and kind of guiding them through that disease process? But if you're trying to do that in 15 or 30 min and answer all these questions, that
Landon Blankenship: that's really difficult. because usually the patients will we usually leave that visit, having more questions, probably, than what they even came with, so
Landon Blankenship: power that can help with that. Now it can help ensure that those patients, the families, the caregivers, understand the aspects of that illness, help them to make informed, well educated choices and decisions.
Landon Blankenship: Once again addressing that spiritual and emotional needs of the patient coordinating care with other members of the health care team coordination and collaboration and palliative care is major, whether it is with the primary care provider which we would prefer to always do. we are not there to
Landon Blankenship: just take that patient or steal that patient from a kind of primary care provider. That relationship with the patient and the Pcp. Is very, very important. Our goal is to be an an extra layer of care. Another set of eyes and ears
Landon Blankenship: to help manage that patient symptoms while coordinating, collaborating with their Pcp. Or home health agencies or oncology centers. Whatever the case may be. to make sure that we take the best care possible for those patients.
Landon Blankenship: And, as I said earlier, of course, our goals is not only to treat the physical, but to treat the the psychosocial and the spiritual aspects of that patient as well.
Landon Blankenship: So when should pallet of care be considered. And naturally, if we're looking at patients who are serious chronic illness, not terminal yet, serious chronic illness.
Landon Blankenship: Those patients who have symptoms that just aren't being aren't getting aren't getting treated or aren't getting. Manage the way that we would need them to. Pain, shortness of breath, fatigue, anxiety, and of course you can see, the list goes on. These are all symptoms that is not on common for pallet or programs to treat patients who have frequent er visits or hospital admissions.
Landon Blankenship: These are all patients. And just in saying this, probably the majority of people on this, on this call right now. you probably have 5, 10, plus people that you know that
Landon Blankenship: they're not having their symptoms managed well, or to the best of your ability. they're getting, repeat er and hospital admissions.
Landon Blankenship: so what is up happening typically is the picture will go in to like the er or the hospital. They get treated medication, you know, with medications. They're getting steroids. They're getting their Iv fluids all that.
Landon Blankenship: and then they get discharged all well, within a week or 2, and all that stuff starts wearing all.
Landon Blankenship: There's probably no one there to monitor their medications to make sure that they're taking them appropriately. there's no one in the home to see what their actual in home needs are, where they even able to afford their medication. that those effects of that hospitalization begin to wear off. So then the patient ends up, going right back to the er or going right back and being emitted to the hospital. So our goal is to just be an extension of the primary care provider or the extension of the specialists.
Landon Blankenship: be it a pulmonologist, a cardiologist on call, and just whatever that may be, to make sure that we are assessing and supporting that patient to to the best of our ability, to try to keep that, keep them out of the hospital.
Landon Blankenship: Another big one is establishing goals or help clarify help to clarify their goals or treatment options. and that can be as simple as which is not simple, but in in the health care world it most would probably view that as simple.
Landon Blankenship: It's discussing code status or discussing advanced directives. It is an appropriate referral. Just to have go clarification with the patient. An appropriate pilot Referral would be to have low go clarification. Looking at that code status, looking at those advanced directives to make sure that that we're doing what the patient may want.
Landon Blankenship: So primary criteria. As I said, you know, there's once again looking through serious chronic illnesses, the surprise question, we often say, would be, You know, with that, would you be surprised if that patient passed within the next year. And if that's the case.
Landon Blankenship: definitely, they're probably already palliative care appropriate. And at this point in time they may even be Hospice. Appropriate. So that's the big question, you know, if we're looking at this patient saying they are probably not going to be here this time next year.
Landon Blankenship: That's a that's a prime candidate for palliative care once again frequent admissions to the hospital, to the er And then, you know, looking at
Landon Blankenship: those symptoms, the symptoms that aren't treated. you know those moderators to severe symptoms of intensity for more than 2448 h. There's the patient having a lot of pain, or they haven't shortness of breath, that is, that is lasting and extending a complex, clear requirements. What's their functional dependency that? How much support do they need at home for feeding or antibiotics, or maybe even they have a ventilator or trilogy, or something to that effect?
Landon Blankenship: And then the client and function is is major as well. decline in weight. That's one of the biggest indicators for us is the client and weight. Those would be patients that we would typically deem as failure to thrive patients. Now, Cms kinds of friends on this using that term anymore. But we all know what that means when we're talking about failure to thrive patients. So
Landon Blankenship: so secondary criteria. Of course, the mission from long-term care facility, or or a medical foster home, elderly patients who are cognitively impaired, metastatic or locally advanced inurable cancer. There's your stage fours, chronic home oxygen use. They're dependent on their oxygen nail
Landon Blankenship: patients who have maybe had cardiac arrest or some major cardiac event in in a facility
Landon Blankenship: limited social support. There's lots of family stress, chronic mental illness. These are all kind of a secondary class of criteria that we would need to look at. And once again, keeping in mind that that goal clarification for that patient would be major.
Landon Blankenship: So we've looked at kind of the who would benefit and all that, and why palliative care. So then we talk about what are the benefits of palliative care, and the the greatest benefit, I think, is how we approach things with the interdisciplinary team approach when we get everyone together who has any aspect of taking care of that patient or being involved in that patient's care.
Landon Blankenship: Set around the table, and, you know, discuss the patient. What are we doing for the patient? What's working? What may not be working? what are their goals? And we're able to discuss all of this in a great detail.
Landon Blankenship: Another is reduced cost, and I know in most health care settings or entities. You really don't like to talk about calls, but it is a very needful thing, especially in today's world. and there's actually estimates out there that having palliative care on board reduced cost of a patient by about 16% and typically with any
Landon Blankenship: you know, cost associated with a hospitalization or something like that. If you're looking at 16% introduction of cost, you're going to be in a thousands and thousands of dollars that a patient is actually saving
Landon Blankenship: or having reduced calls. just by having palliative care on board.
Landon Blankenship: The biggest, of course, is in 3 patient outcomes, and when we talk about information outcomes, one of the terms that we hear a lot of times now is the social determinants of health, and these are major. it's those non medical needs. And oftentimes we, we fail to to see a lot of these, but they have a great impact
Landon Blankenship: on our patients outcomes nutrition transportation. do they have a social or caregiver support housing, you know, we may. When the patients discharge from the hospital, you know they get their their prescriptions.
Landon Blankenship: but if a patient is unable because they lack transportation, if the patient's unable to get to the pharmacy to pick up those medications.
Landon Blankenship: or they're having to choose between. Do I buy food, or do I buy my medications? they're probably going to go to the food route. So those are those social shows. Social determinants of health are, major. When we're looking at.
Landon Blankenship: you know this patients location? Why are they being re-admitted to the hospital? Why are we not getting their symptoms under control and palliative care really is in the home the majority of the time they're there. They're looking at these things, determining what the patient may or may not need. That's outside the scope of their actual physical disease process.
Landon Blankenship: and then gives the patient a voice, there go clarification.
Landon Blankenship: How many times do we sit down with the patient and their patient and the family are on to totally opposite into the scale, and palliative care tries to come in and mediate and do what the patient wants, as well as educating the family to try to get them. get them on board. So
Landon Blankenship: so that's pilot. They're important to facilities. Well, actually, I think everyone is under the microscope today, be it a home health agency, a skilled nursing facility.
Landon Blankenship: be it palliative, Hospice, whatever everyone's under the the radar of looking at. Okay, why are your patients being re-admitted to the hospital? Why are they going back to the hospital? But we also know that you know there's now this care. Compare out there that everyone is kind of can get on the Internet and look at to that compares agencies. But the big thing is is, we know for their Co. Pd, heart failure, stroke patients, pneumonia patients.
Landon Blankenship: and those are the primary class of patients, especially in in our area, that are being readmitted to the hospital very frequently, so palliative care comes in. If we can decrease a patient going to the hospital
Landon Blankenship: from 2 times a month to one time, every 2 to 3 months. That's when, for everyone involved not only palliative care, not only the patient, but also the hospital or the facility that that patient is from. So you know that that is a when with everyone, I think there's lots of research out there that proves that palliative care actually does a very, very good job of helping maintain these patients symptoms to keep them out of the hospital.
Landon Blankenship: So we consulted ballot of care. Now, what new cons, also valid care usually seen within one to 2 weeks. So once you send in a a referral unlike Hospice, which the majority of times is probably out there within 24
Landon Blankenship: to 48 h, if not less. it may take a little longer for a palliative care provider to get there to that patient and The reason being is.
Landon Blankenship: there's a lot of pilot providers. Their schedules are made much like a doctor's office would be. So they have patients who are actually already scheduled. And we're plugging those new patients in there. So our goal is about 7 days or less and the majority of time. I think we we meet that standard. But know that once you do a pallet or
Landon Blankenship: palliative care referral it's probably gonna take at least a week for someone to get there to see that patient. Now the patient will remain, as I said earlier, under the care of their primary care, provider and specialist. Once you come with palliative care, you don't stop seeing your physician. You don't stop seeing your oncologist, your nephropologist, whoever we want you to maintain those contacts with those positions, and then the visit frequency is based on risk stratification.
Landon Blankenship: When we look at risk stratification. We're also looking at how visits should be made. So
Landon Blankenship: you know, a lot of times that's depending on the patient's functionality. How may you know how many symptoms that you're having that's managed or not managed. But for the majority of time you're going to get a nurse practitioner once to twice monthly. you're going to get an Rn. Or or maybe even Lpn depending on the program to go in and follow up, provide education for that patient, and then a social work as needed. So
Landon Blankenship: so I've console to power care now what the big thing is is, you know, the care provider we went over that we've identified needs clarifying goals, communicating with the providers.
Landon Blankenship: educating and counseling the patient family and then giving recommendations and or treatment. So some palliative care programs will actually treat the patient They may order antibiotics. They may adjust lasics for someone who is chf and shorter breath. they may order nausea medication for someone who's
Landon Blankenship: under the care of an oncologist? who is you know, receiving team of therapy. So some may treat or some programs actually just make recommendations, which is I've seen this patient of evaluated them. This is what I would recommend. And then their provider actually, the PE primary care provider specialist actually orders those medications.
Landon Blankenship: So palliative care patients actually continue service until one following happened. The patient request, discontinuation of services. A patient may leave palliative services at any time they wish. The patient no longer meets palliative care. Criteria
Landon Blankenship: The patient, of course, would pass away, or they transition to Hospice. And that happens a lot. You know, we we have patients on pallet of services. We identify that they're now Hospice appropriate. And then they can actually transition over to to hospice care or the physician request the patient no longer see palliative care services.
Landon Blankenship: So, Casey, I want to stop right here just for a minute or 2 to take any questions that anyone may have regarding Pallad of services.
Landon Blankenship: before we go one into Hospice, because probably people have a little bit better understanding of Hospice than they do. Palliative. So is.
Landon Blankenship: I think, Casey. I think you were handling the question. So if anyone has a question, I would be more than happy to take those just for a minute.
Kasey Stevens | Quality Insights: Yep, Landon, we've got one question so far. It's how often do you see positions requesting discontinuation of services
Landon Blankenship: doesn't happen too often. the majority of time, once ballot of services are started. a a physician would want to continue those continue their services because it's kind of a win-win for the patient and for the physician as well. because, you know, if your patients in the home and they're having urinary. you know, uti symptoms. You're retract infection symptoms, and the pilot providers there, they're, you know, doing the appropriate
Landon Blankenship: follow up with that patient, and then, of course, as I said, they're either going to recommend or treat that some of that depends on the physician, the prime Pcp. But they can either go in maybe order antibiotic for that patient, or let the physician that hey? This is going on there.
Landon Blankenship: Maybe when you go back to the er we can go ahead and treat this in the home. So this continuation of services from from a physician request doesn't happen too often, but it is. It is a possibility.
Kasey Stevens | Quality Insights: Fantastic. Thanks. Landing a couple of more questions coming in here. Can a patient have home health, palliative care, and a caregiver at the same time.
Landon Blankenship: really benefits the patient is when they're actually able to have home health and palliative care. because there's probably going to come a point in time in that patients disease process that maybe A home health agency says, well, we can no longer skill this patient. There's nothing that we can take them on the services for.
Landon Blankenship: So when home health actually pulls out of that patient's care. they're probably not Hospice appropriate at this time. So there's kind of a gap in care there. So you're between not being home health appropriate, not being hospice appropriate. So what happens to the patient? Well, palliative care is a great a great resource to have there to kind of
Landon Blankenship: have someone in the home between that time or to the patient needs home health again. for maybe another reason having someone there in the Home to monitor that patient during that time. to make sure that they're they're taking care of. So and usually there's not an issue with having caregivers in the Home.
Landon Blankenship: palliative care on like hospice. Palliative care usually doesn't have home health aids that work with them. That's more on the the Hospice side. so usually there's not an issue with that. Now, from a Hospice standpoint.
Landon Blankenship: You can't have duplication of services, so you know, it may be that you know either those, if they're from an agency and it's not private pay, then their services may have to end, or you have to work it out on opposite day, so that you're not giving a duplication of services.
Kasey Stevens | Quality Insights: Fantastic? Thank you.
Kasey Stevens | Quality Insights: Can patients request palliative care, or does it need to be physician generated?
Landon Blankenship: patients can make a request for palliative for palliative services? but the majority, I think, of palliative providers is
Landon Blankenship: at some point in time a either before you're seeing on services, and that really depends on the the the program, I think, either before you're seeing a pilot they're going to reach out to at least the Pcp. To say, Hey, we have a referral in this spaceship. We're going out to see them, or, you know, do you want to work with us collaboratively? Or you know, what actually would you like for us to do for this patient. So they're a either going to reach out to the Pcp. Prior to, or they're just going to inform the Pcp. That, hey?
Landon Blankenship: This patient has called and requested a referral.
Landon Blankenship: we're gonna go ahead and see them and then send them the notes. from the visit so that
Landon Blankenship: that can happen one of 2 ways, and it really depends on the the program. So
Kasey Stevens | Quality Insights: thank you. Got time for a couple of more questions here. We did what would be an example of a physician requesting a patient no longer receive palliative services, and can the patient refuse and still request palliative care.
Landon Blankenship: I really can't think of a situation right off top of my head where a physician and no longer want their patient to receipt palliative services.
Landon Blankenship: on last there would be a situation
Landon Blankenship: to where we have kind of gotten the patient to the point that they're kind of stable, and rather than having palliative care coming in, the physician may just want to oversee that patient. Them sales until they would need palliative care again, because it's not uncommon for palliative for patients
Landon Blankenship: to come on to services. You get them at a good place, get their symptoms, trees, and eventually they may go all palleted services. But once again, this is a chronic illness. There's no cure for those chronic illnesses. So eventually they're probably going to come back onto your services. That would be the only reason that I could think of that. A physician may request that. And I'm sorry. What was the second part of that question.
Kasey Stevens | Quality Insights: and so can the patient refuse and still request palliative care?
Landon Blankenship: I think that's probably a possibility. you know, if a if a physician would not want the patient to receive services, but the patient does want to receive services. I I think that is a possibility, because.
Landon Blankenship: you know, there is a medical director associated with palliative care as well. So that doesn't happen often, but that that could be a possibility.
Kasey Stevens | Quality Insights: Great. Thank you. We've got 2 more here.
Kasey Stevens | Quality Insights: If the patient is in the Va. Home-based care system, this palliative care work with them as well as a private primary care physician.
Landon Blankenship: that's a great question, and I think it probably depends. The the answer was, Yes, but I think there's been
Landon Blankenship: some push back here recently with the Va. Because they are now stating that the Va. Is providing their own palliative care services, or at least that's what we're getting with our program. So the Va. Will not will not permit the patient to receive in home palliative care services.
Landon Blankenship: because the Va says that they are providing those services so they will not authorize those visits for payment. so that has been a very recent change of events.
Landon Blankenship: and to my knowledge, I'm assuming it's like that everywhere. So.
Landon Blankenship: but the Va home based primary care program is a is a wonderful program, I think. they do their veterans a great service.
Landon Blankenship: and they they kind of do a a lot of of what palliative care would do but
Landon Blankenship: At the same time there's still some things there that pilot could definitely benefit their their veterans with
Kasey Stevens | Quality Insights: the last one here, for now? If a person is on Medicaid, does that affect services?
Landon Blankenship: No, The majority of
Landon Blankenship: so public care is kind of the newer thing out there. So you know, for most insurance is be a private insurance, for example, you may call them up, and they they have no idea what we do. Even though we try to educate. They they still have difficulty, sometimes understanding but usually Medicaid is not a I don't think is a factor in that. So
Landon Blankenship: and that may depend on the program. I'm just, you know, speaking from our standpoint, or where where I work. But it it really, it may depend on the program, too. So
Landon Blankenship: that's all the pound of care questions we have for a moment. Okay, well, we're going to continue here. so then we will look at Hospice. And what does Hospice have the offer? And if you look.
Landon Blankenship: it's a little diagram here. Hospice is very patient, family focused, family centered, and a patient may have all of the services or some aspect of the services at any time throughout their their Hospice day. Once again we're looking at quality of life, even on the Hospice side. But hospice is comfort, care. So once again, I'm gonna rephrase this
Landon Blankenship: palliative. They can seek that aggressive treatment. Remember your A B and C palliative. They can see that aggressive treatment.
Landon Blankenship: they can, you know, get their dialysis. They can still have their chemotherapy, the radiation, and all that
Landon Blankenship: and still get their symptoms manage, whereas in Hospice care they're kind of at the end of their chronic illness. They're now terminal. So we are looking at primary comfort, care for that patient. They're not seeking progressive treatment.
Landon Blankenship: so Hospice is a whole package of care services that is almost always provided at the patients home, whether it's a private residence or in a or in a care facility. So
Landon Blankenship: question usually comes up as well. When should Hospice be considered? We said earlier that you know, if you're looking at about a year out. That's usually the rule phone. If you're looking about a year, maybe that that patients probably already palliative care appropriate and maybe Hospice appropriate, but I like to refer everything to to trajectory. And this
Landon Blankenship: is the best graph. I think, that I've that I've ever found or utilized in doing education to help people to understand. And these are primarily true. I think if you look at, for example, a cancer patient that could be a cancer of almost any origin.
Landon Blankenship: There's kind of a slow decline for that patient until you get to a certain point. Once you get, they get reach a certain point in their disease process. There is a drastic decline in that patient to the end of life. So an example of receiving palliative care services may be back up toward the top there, where that that patient is kind of plateaued out.
Landon Blankenship: but naturally we want to try to get Hospice on board sooner, if possible for those patients, whereas if it's an organ failure, and that's any type Co, Pd, caf, liver whatever the case may be, you're going to see
Landon Blankenship: dips in their in their levels of health. For example, patient may be doing well, and then they get sick. They go to the hospital, so they're really sick, and then they improve a little bit. But they're never back up here where they were, and it's that constant continual decline of going into the hospital coming back out, but they're not as good as they once was, and they get do okay? Then they, you know, they
Landon Blankenship: go get sick again, usually go to the hospital, and that's that's typical. And where, as you look at cognitive frailty, they're almost kind of a flat one. These are your patients that have
Landon Blankenship: you know your Alzheimer's or your dementia? Maybe even Parkinson's
Landon Blankenship: those are your patients on Hospice care that typically or your longer lengths of stay patients? because their their decline is almost at a flat line. So this is very good. And I, I use this even in discussing a patients, conditions with families. A lot.
Landon Blankenship: So hospice referrals.
Landon Blankenship: you know, if we're looking at hospice referrals, the calling sources of the missions. Of course we do get referrals from emergency rooms a lot of times, inpatient hospital states, primary care physicians or rural health clinics, or federally federally qualified health clinics, F, 2 Hcs
Landon Blankenship: palliative care, of course, is a source of referrals for hospice clinics specialists. V, it, oncologist cardiologists.
Landon Blankenship: But a lot of times your referral sources comes from patient family. probably, I think overall if you look statistically hospitals are probably the the number one referral source. Usually they're up there at the top. And then, you know, it's not on common for your your patient and your family to kind of be somewhere in that second, maybe third range there, depending on location. because a lot of what Hospice does is by word of mouth. You know, this person will go tell someone else.
Landon Blankenship: Hey? You know we received Hospice care. This is, you know, this is a wonderful service that really really helped us, and then, you know, at that token, then they will go ahead and make referral and sales. But anyone can make a referral to Hospice. I want to make that clear. anybody at any time can make refer to hospice it could be
Landon Blankenship: family nurse. Whoever anyone can make a referral, so physicians can continue to manage the patient with the support of Hospice, with the support of the Hospice medical director or the
Landon Blankenship: The Hospice medical director can provide full management, and that depends on the patient. The patient has the ability to elect which physician that they would like to cover them at the end of their life, and another Hospice care that is their right
Landon Blankenship: to elect their physician to to monitor them.
Landon Blankenship: hospice appropriateness and and admission. So a home hospice, of course, we're looking at a patient
Landon Blankenship: that has a terminal disease with approximately 6 months or less to live. Any physician once again can refer hospice, medical director, and our end review all admissions. So we have a set of criteria that we have to go by. Palliative care really doesn't have that right now. We're looking at some admission criteria and getting that in play for providers, so they'll know. But we have by Medicare Medicaid service. We have a set of criteria that we have to go by, and that is a suggestion for this patient to say
Landon Blankenship: they should have these things or their disease process should include these things. So this is what a hospital patient should look like. So usually the medical director, the nurses they were, view all those admissions to make sure that they're meeting those criteria before that patient comes on to services
Landon Blankenship: inpatient, or sometimes it's referred to as general inpatient hospice admissions. Those are patients who have uncontrolled symptoms, so they may have respirations in the forties. they're having on controlled pain. Because typically for, like your cancer patients, they would do okay. And then all of a sudden, they get in a pain crisis. So that's probably because they're really getting near the end of there's these processes probably going to start the dying process relatively soon, because
Landon Blankenship: pain is typically associated with that. So having those on controlled symptoms would would be a reason for in what we call inpatient hospice admission and that may be in a facility in a hospice facility, for example.
Landon Blankenship: respite, care, admission is for hospice and rope patients. These are, Medicare says that any patient who is receiving hospice care can have up to 5 days of respite, care in a in a facility, and that's a 24 h care. and we know that caregiving is the most difficult thing out there today. That's the most difficult job out there. So respite care goes a long way in helping our patients
Landon Blankenship: and families. So let's look at palladic care versus hospice care. So we've looked at the differences in the 2 hospice versus palliative And you know, in that sense we have to do a lot of of
Landon Blankenship: let's go clarify that. We also have to re what I like to call reframing goals, because, you know, power of care. They patients may be a little more open to palliative care, but you mentioned hospice care, and it's like near the headlights. You just mentioned the H word So we have to a lot of reframing goals, and I often tell people that you know, if you go from a standpoint of receiving a chronic illness to now treatment is failed. Your terminal
Landon Blankenship: you know there's not another surgery. There isn't another medication. Then, Hospice care. We kind of refrain those goals, because at that point in time, since we're focused on
Landon Blankenship: comfort, we're kind of looking at. Well, the patient hopes they won't be that they won't have painted the end of life, or they hope they won't have nausea vomiting. They hope that they'll get to spend time with their loved ones, and that's what we do. A lot of people say. Well, when you go from PAL to to Hospice, or the patient goes to Hospice. Then there, you know, there is no hope there, and I like to disagree with that and say, No, there's still hope. We are just
Landon Blankenship: reframing those goals, and reframing that hope into something more toward the end of life.
Landon Blankenship: So hospice care versus ballot of cater. So what are the differences in the team, continuing on with what we already talked about. Palliative care, again, is a little. The patient will have a life threatening, or, as hospice care, they are terminal. They will have a terminal illness at that point in time, with a prognosis of 6 months or less to leave. Now, naturally.
Landon Blankenship: we don't have a crystal ball to say, this patient's going to pass away in the next 6 months. So we have what we call recertification periods for our hospice patients, and they have to be reevaluated for those to see if they're still meeting those set qualifications or guidelines that I mentioned to you all that was set forth by.
Landon Blankenship: It's gonna seems so power of cares, life threatening, cigarettes chronic, whereas hospice is terminal once again, both of them have to do with quality of life. But with Polycare we're reducing illness symptoms. that is a big one of reducing or getting their symptoms under care, whereas in hospice care dignity, dignity in the life is, major. I think any of us would want a dignified passing.
Landon Blankenship: So making sure that we're maintaining the dignity for that patient, and to the best of our ability, giving them a pain free a pain-free, that
Landon Blankenship: so power of care, Hospice care, neither of those depending on age so they can have from babies to pediatric patients all the way up to the very geriatric
Landon Blankenship: patient. So neither one of those are depending on age. The big difference is once again pile of cares for that serious chronic illness where, as hospice care, we're looking at that terminal diagnosis, a P. Of care is not dependent on our prognosis. You may have a ballot of care patient for years.
Landon Blankenship: we're as hospice care. We're looking at that page, having a prognosis of 6 months or less to leap now
Landon Blankenship: the pallet, and once again can be provided along with your to treatment, whereas hospice care they cannot seek aggressive curative treatment because we are primarily focused on comfort.
Landon Blankenship: pallador versus hospice. If you look at these, they're primarily the same slide supportive care system, management, education. So we're everything is the same
Landon Blankenship: as far as you, and enhancing quality of life all the way down to the end, and that is palliative care. Once again, as I toj out earlier, we're looking at treating them earlier in the disease course or as hospice care. We are looking at later in the disease. Course, you know, I think it's really interesting, too, because when when we talk about this, we often you know, patients
Landon Blankenship: often think you know. Well, I'm going on. I'm leaving Power going on to Hospice. And unfortunately, I mean, I'm just being honest. A lot of people, you know. As I said earlier. They get that
Landon Blankenship: fear you know, of of Hospice, but if they, if you look, statistically speaking, a patient will live about 28 days longer, receiving Hospice care than they will seeking regressive treatment to hospital. And if you think back to that diagram of all the services that are offered with Hospice care and what palliative is able to do on the front end of that and we know that patients do much better in their home.
Landon Blankenship: in their comfortable environment. Then they do in a hospital where we're doing lots of test. And you know all this other stuff.
Landon Blankenship: They they patients tend to live longer on average, about 28 days longer under Hospice care, which is which is major. So for years, I think we're under the old
Landon Blankenship: model of care. you had a diagnosis. Let's say, Ch, if you had a diagnosis to get all throughout this life prolonging care, you know, you're receiving all this treatment or multiple hospitalizations. in and out of the hospital all that. And then, all of a sudden, maybe you
Landon Blankenship: want to go to Hospice. pass away on Hospice. Well, really, I think where we need to be is with the new. So patient gets diagnosed with with caf, they may be in the hospital to get diagnosed with chf.
Landon Blankenship: that's a good time to introduce palliative care services. Now, at the front end of this, that life prolonging care, they're still able to do a lot for that patient. But over time the treatment options that they have are going to diminish because, you know, they're running out treatment options. And when that happens, introducing palliative care early, when treatment options begin to decrease, what power that is able to do increases, and then we're able
Landon Blankenship: hopefully get the patient. Maybe on Hospice care even sooner sooner than possible, so or sooner than we, we would have otherwise. So we really need to try to move towards the model to where we're introducing palliative care much sooner for the patient.
Landon Blankenship: So where our services available medical facilities, nursing facilities, assistant living facilities, and in the home. pretty much anywhere that you can almost think about. services can can be provided now on the palliative side. we just don't, you know.
Landon Blankenship: By law. Hospice Hospice is offered in these places on the palliative side. For example, we, you know, have to make sure that we're working with the A like a skilled facility before we can just go in there and provide services.
Landon Blankenship: because we we don't want to cross any bounds that they may have or break any rules that they may have regarding their organization or their facilities. So we we want to make sure that we're complying with that. So
Landon Blankenship: and our goal is is to be everywhere, I guess, is what I should say.
Landon Blankenship: So this is some good examples of of the different patients that you may see, for example, the stage for metastatic breast cancer with metastatic disease to the brain, lungs, bone wake, oriented eating, drinking, but not a Canada for chemotherapy. but not a not a candidate for chemo radiation. That would be a patient who is hospice appropriate. They're not a candidate for treatment.
whereas the flip side of that you got to have the same thing, but they are actively taking chemotherapy and radiation. This is an appropriate
Landon Blankenship: example of a hospice versus palliative care. Patient Alzheimer's disease. We're very familiar with the fast score. a patient who is at least a 7 a on a fast force office appropriate. whereas those Alzheimer's patients
Landon Blankenship: that are less than a 7 a. On that from that fast scale are probably more palliative, appropriate at that time. Example, for zhf, with the difference between class 3. Heart failure class, 4. Heart failure
Landon Blankenship: stage for prostate cancer with metastatic diseases, the bone liver receiving pallet of radiation. Patients can get what we call valid radiation. Sometimes in hospice care. it's for the palliation or re re relief of symptoms. we're as in stage 4, prostate cancer with metastatic diseases, the bone liver
Landon Blankenship: their status post prostate removal, and they're waiting a radiation console. So I don't want anyone to get confused with the palette of radiation thing. But that I do have. I do have to mention that that may be a possibility for symptom, control and comfort. And we don't typically do like aggressive treatment. And all that The pallet of radiation is usually decided on by the Hospice Medical director in conjunction with an oncologist.
Landon Blankenship: Maybe if the patient has pain that is not being able to be treated or as effective as affected by the narcotics
Landon Blankenship: so Pd. With disabling Disney and oxygen dependent increase exacerbations of hospitalizations. The spot therapy that would be a hospice appropriate patient, and
Landon Blankenship: the difference for that for power. It would just be an oxygen-dependent Co. Pd patient. So this kind of brings out some differences in what a hospice and palliative patient would look like once again for the sake of time. I'm not really going to go into this this much. I think this we've already kind of went over this. So this is just kind of a review for us.
Landon Blankenship: Here's the big one, the Referrals, and they it. The issue is, I think, any palliative or hospice program would tell you. The same thing is, there is a problem with referrals, and we're either getting delayed referrals, an example that would be a hospice referral that you get, and you only have them for a couple of hours to less than 24 h.
Landon Blankenship: We need patients much sooner on that end, you know, we, we need patients. It would be nice if we had patients 3 or 4 months, because once again, if you think back to that slide of all the services that they have. If you get a patient in within 24 h, we may need our goal of making that patient comfortable by by the end of their by the time they pass away. But unfortunately, there's been a lot of services that they've missed out on
Landon Blankenship: so delayed referrals or major issue, especially with Hospice, because, you know we should be having those patients much sooner, not within the last hours of their life. But
Landon Blankenship: we'll still do our job and take them on. We can absent referrals patients who are not referred to. Palliative care not referred to. Hospice.
Landon Blankenship: this is could be a 2 way street. Either the the primary care provider or the the specialist is not on board with one of the 2 of those programs, or maybe even both of those programs. Or it's the family who does not want that referral put through yet. So that can be 2 different ways. But we really really need timely referrals. Culture can play into that.
Landon Blankenship: I tell people all the time where we're located here in Southern West Virginia, it's not on common in this affection culture for families to say, we we take care of our own. We don't want someone else in here taking care of our loved one, but
Landon Blankenship: once they do allow you to come in. Then you're like family. They treat you like family, and it's a wonderful thing. But we're trying to change the thing with knowledge deficit, you know. That's the reason we do things like this really trying to improve the knowledge of what the programs are
Landon Blankenship: and decrease that refusal to accept change because it is very. These are both very, very important programs
Landon Blankenship: that our patients need. It's it's very important for them to to have these offered to them, to allow to allow that good care, that acceptable care at the end of their at the end of their life. So
Landon Blankenship: one of my favorite coach and patch atoms our job, our job is improving, the quality of life, not just delaying death, and we can get called up in delaying death. And there's a I want sort of a a physician. Say, there's 2 things that you can't stop that's getting older and dying. There are no cure for either of those things. So our ultimate goal needs to be to improve the quality of their life, not just trying to delay their dad.
Landon Blankenship: So with a few minutes left, I want to turn it back over to casing to where we might be able to answer a few more questions.
Kasey Stevens | Quality Insights: Absolutely. Thank you so much, Landon. Great! We've got a couple of questions coming in here. The first one is respite. Care for hospice is only for those in the home setting correct. It is my understanding. Those in a group, home, etc. Do not qualify.
Landon Blankenship: you you have. You have to kind of be careful with that one, because The the major reason for respite. Care is for caregiver breakdown. That's what That's what respite care is primarily for. So let's say you're in a assistant living facility with 24 h caregivers who rotate because of shifts.
Landon Blankenship: That would be difficult in my opinion that would be difficult to justify. Respite. Care? Because you you don't have the same caregiver there continually around the clock
Landon Blankenship: good example of the need for respite. Care would be your little 80 plus year old.
Landon Blankenship: like a lady who's taking care of her husband, who has dementia, who has sundowners, and she has a slept in 2 days. That would be a prime example of someone who really need drastic here.
Kasey Stevens | Quality Insights: Awesome. Thank you.
Kasey Stevens | Quality Insights: Would a poorly controlled diabetic qualify for palliative, or would they not at all.
Landon Blankenship: I think, that may very well be an appropriate diagnosis for for a palliative care referral.
Landon Blankenship: naturally, we would probably collaborate with the
Landon Blankenship: the patients endocrinologist or their primary care provider to try to make sure that you know we're getting better glucose control, but definitely for patients who have poorly controlled diabetes and have additional symptoms. maybe skin issues or wound issues
Landon Blankenship: kidney issues in relation to that, that I think that would be a a very appropriate
Landon Blankenship: diagnosis for palliative services.
Kasey Stevens | Quality Insights: Great! Thank you. Do you have many people with intellectual disabilities, receiving either care.
Landon Blankenship: I think that varies
Landon Blankenship: I think the answer to that is
Landon Blankenship: probably regardless of the spectrum of, or anyone would be on the it.
Landon Blankenship: You know, a child with, you know, parents who are just now going through this
Landon Blankenship: this new diagnosis to people who might have intellectual, you know. Disabilities. all the way up to the geriatric patient. I I think I think it really depends on where they're at. But yes, the ultimate answer to that is, yes, we do have patients.
Landon Blankenship: that struggle with that. And you know we we do the best we can do and reach out and try to get other services on board. Collaborate with other services, either, and maybe even community services that is available to the patient to help out in those situations.
Kasey Stevens | Quality Insights: Okay, thank you. How do you find palliative care? Providers in your local region? Hospice providers seem more common. Do you have any tips.
Landon Blankenship: I know for us here in West for you. You have the Western new Hospice Council, and a lot of times you can go on there and do a a search by you probably do a a Google search or reach out to your local hospice agent. I think all the Pallader programs in the State of West Virginia right now are all
Landon Blankenship: or all under the arm. I guess you could say or attach to, or in conjunction with a hospice program. and once again, there' 2 2 totally separate programs. but that's kind of the way it it appears right now. So I think if you reach out to one of those Hospice agencies and ask about palliative services, they might be able to to steer you in the right direction.
Kasey Stevens | Quality Insights: Fantastic. Thank you so much later that wraps up. all the questions we had for today and all the time we had But I do need to make sure we have time. for folks that need the Zoom credits
Kasey Stevens | Quality Insights: in a moment for those wanting to credits for nursing, nursing, home administrators and positions. You're not here for ce credits. Please ignore the link that I'm about to send out. You're not sticking around for a Ce. Credits you can sign off at this time. Thank you so much, Landon, for presenting today super informational. We really appreciate you taking the time with your busy schedule to help educate our folks.
Landon Blankenship: Thank you so much. Everyone have a good day.
Kasey Stevens | Quality Insights: all righty. And as we said, at the beginning of the webinar land, and if you don't care to click to that next slide
Kasey Stevens | Quality Insights: those who are interested in receiving CD credits are going to need to complete an evaluation about to drop in the chat window.
Kasey Stevens | Quality Insights: in order to receive your free nursing position or nursing home ce credits and certificate of completion. You will need to complete a evaluation and post knowledge check. Once you successfully complete the post knowledge check, you'll be forwarded to your certificate.
Kasey Stevens | Quality Insights: so as you can see here, we have a few ways. You can pull up that a knowledge check. in a moment. I'm going to put the link in the chat for everyone. You can also complete your evaluation on your phone or tablet by scanning the QR code. That's on the screen right now.
Kasey Stevens | Quality Insights: where you can wait until it in the webinar we'll be sending out the slide deck as well as a link to the evaluation so you can complete it. if you have folks that weren't able to attend today, they can watch the recorded webinar, and there will be a different link for watching the recorded and doing the recorded evaluation as well.
Kasey Stevens | Quality Insights: If you have any questions about the Ce or certificate of completion, please. Email. Andrea left K, And I'm going to drop her email address in the chat. And if you have any other questions for me as well, I'm going to put my email address as well as land in in the chat. So that way, you're able to answer any questions you have again. Thank you so much for joining us today. We really appreciate it and hope you have guys have a great rest of your Wednesday.
Landon Blankenship: Thank you. Have a good day.