Download - Objectives
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LifeCourse: A Late Life Supportive Care Research Project
Sandy Schellinger, RN MSN NP-CCo-Investigator Center for Healthcare Research and Innovation
Allina Division of Applied Research
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Objectives
Participants will be able to:
Describe the LifeCourse Late Life Supportive Care Model
Understand and describe how advance care planning should be integrated into the late life experience.
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A Robina Foundation grant in partnership with
Abbott Northwestern Hospital, Allina Clinic and
Community Division, independent physicians,
Walker Methodist, and Augustana Care to
develop a new supportive care model for
individuals late in life.
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All diag
noses
Spre
ad to
regio
nal hosp
itals/
clinics
Develop pati
ent selecti
on algo
rithm
Enro
ll 12 – 30 te
st pati
ents
Dx: Hear
t fail
ure, S
tage
3-4 cance
r,
Dementia
2012
Phase I: Design/build care model
2013 - 2014 2015 - 2017
Enro
ll and st
udy 250– 5
00 patien
ts
Estab
lish busin
ess m
odel
Phase II: Validation
6-Year Study Timeline
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Model Foundation:The Felt Experiences of Care
• Wife of a chronically ill husband: “We’ve been in the hospital and five
different care centers. It’s like starting over every time.”
• A family caregiver: “Hospice was great. We couldn’t have done it
without them. But all of a sudden they took over and said, ‘You can be the
family now.’ I felt like our years of caregiving were invisible.”
• A son caring for his father at home: “The only time I felt out of control
of my dad’s care was when we went into the hospital.”
• A surgeon at Abbott Northwestern: “How can we reclaim the heart of
medicine?”
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AIMAs I live well with serious illness, I am in charge.
You listen to me, help me, guide me, honor me, and support me as a person.
Relationship based patient centered support across care settings in the last years of life will prove to
reliably honor and respect patient goals and wishes, improve quality of life, enhance the care experience
and reduce unwanted or unnecessary care.
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relationship + storyRelationship as how to do work
Relationship as result of work
STORY
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THE WORK_domains
Culture
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THE WORK_Guiding Principles
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THE MODEL_Active Ingredients
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Patient & Caregiver Outcomes
Patient Experience
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Care Team Outcomes & Process Evaluation
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Care Team Activity
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System Outcomes
Hospice Enrollment
Hospice Days
Inpatient Days
Total Cost of Care
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How Will We Do This?
The LifeCourse non-clinical care guide establishes an
ongoing, personal relationship to hear the life story and
understand goals of living.
The team supporting the care guide helps to maintain
focus on the whole person, so that non-medical as well
as medical goals are established and supported.
The care guide partners with patients and caregivers to
get the right support from within Allina, from their
community, and from the family’s own strengths and
assets. 16
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M&FT
Care guide vs TeamShared relationship
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Care guide
Chaplain
Participant and
Caregivers
Pharmacy
SW
RN
• The team shares a connection with the patient.
• The care guide provides continuity over time; the clinicians provide focused expertise.
• Therapeutic relationship (care guide) is not the same as Therapy (clinician).
PCP
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• The team for 300-500 patients: – 9 care guides– An RN– A Social Worker– A Marriage and Family Therapist– A Chaplain– A Pharmacist
• Care Guides– Two years of post-secondary education– Experience in loss or caregiving– Good communication skills
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The LifeCourse Model
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• Assessment• Advance Planning
– Shared decision making– Advance Care Planning
• Communication• Coordination• Team Dynamics• Cultural understanding• Critical thinking and clinical
judgment• Facilitator of learning• Process Improvement• Systems thinking
Team: Skills and Licenses— Weighted in favor of a common set of interpersonal skills
Common Knowledge
Base
• Discipline-specific competencies
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Discipline- Specific
skills
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What are the training concepts and foundations? Training Patient Care
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Late Life Adaptive Practice
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Patient and families
productive range of adaptation,
engagement and coping.
Patient and families
productive range of adaptation,
engagement and coping.
Limit of toleranceLimit of tolerance
Threshold of learningThreshold of learning
Based on Heifeitz, R. and Limky, M. Leadership on the line. Harvard Business School Press. Boston, MA, 2002, page 108. Based on Heifeitz, R. and Limky, M. Leadership on the line. Harvard Business School Press. Boston, MA, 2002, page 108.
DISTRESS!
DISTRESS! TimeTime
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A Life’s Journey
• Chuck was 81 years old: a father, a veteran, a man of strong faith.
• He was an engineer who loved to golf, fish, and work in his woodshop.
• He died at home of heart failure 12 years after a kidney transplant.
• In his last year of life, Chuck and his wife faced many challenges.
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• Weight loss, weakness, fatigue, fluid retention, shortness of breath, anxiety, depression, insomnia, anticoagulation, general malaise, osteo-arthritic pain.
• Hospitalization Comfort care vs limited intervention vs full treatment• Shortness of breath Oxygen & morphine versus Diuresis renal failure
vs heart failure.• Fluid retentions Peritoneal versus hemo dialysis• Anemia Procrit; Iron infusions• Malnutrition upper GI
Aortic StenosisPulmonary Hypertension
Renal FailureRecurrent Pneumonia
Aortic StenosisPulmonary Hypertension
Renal FailureRecurrent Pneumonia
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ACP OR SDM?
Illness TIME Death
Lo
w
B
urd
en o
f ill
nes
s
Hig
h
adap
tati
on
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• Patient Centered• Individualized• Whole person• Decision Making• Goals, values
and preference dependent
• Patient Centered• Individualized• Whole person• Decision Making• Goals, values
and preference dependent
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• Present• Specific Decision• Multiple Choices• Life or treatment
options• Change in goals,
prognosis, health status, support, medical plan
• Collaborative Conversation
• Present• Specific Decision• Multiple Choices• Life or treatment
options• Change in goals,
prognosis, health status, support, medical plan
• Collaborative Conversation
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• Future• Surrogate decision
making• Unplanned
Complications• Planning for bad
outcomes• Change in goals,
prognosis, health status, support, medical plan
• Future• Surrogate decision
making• Unplanned
Complications• Planning for bad
outcomes• Change in goals,
prognosis, health status, support, medical plan
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Advance Care Planning is …
• Discussion to understand and clarify goals, values and wishes and decide on treatment options.
• Document Goals, values and treatment wishes into an advance directive document.
• Communicate to others verbally and in medical record the most recent documentation and discussion.
Hos
pita
l Adm
issi
on
Chan
ge in
Con
ditio
n Ca
re T
rans
ition
Hos
pita
l Adm
issi
on
Chan
ge in
Con
ditio
n Ca
re T
rans
ition
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Life Course of Advance Care Planning
Prevention-Wellness-Illness Management-Acute Care-End of Life
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31Life Course of Advance Care PlanningPrevention-Wellness-Illness Management-Acute Care-End of Life
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Life Course of Advance Care Planning
Prevention-Wellness-Illness Management-Acute Care-End of Life
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Life Course of Advance Care Planning
Prevention-Wellness-Illness Management-Acute Care-End of Life
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Patient’s Journey ACP vs. SDM
Illness TIME Death
Lo
w
B
urd
en o
f ill
nes
s
Hig
h
adap
tati
on
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• Present• Specific Decision• Multiple Choices• Life or treatment
options• Change in goals,
prognosis, health status, support, medical plan
• Collaborative Conversation
• Present• Specific Decision• Multiple Choices• Life or treatment
options• Change in goals,
prognosis, health status, support, medical plan
• Collaborative Conversation
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Decisional Conflict
Signs & Symptoms
Concerned about “bad results”
Wavering between choices
Delaying decision
Questioning what is important
Distressed/tense
Preoccupied with decision
“A state of uncertainty about the course of action to be taken when choice among competing actions involves risk, loss, or
challenge to personal values.”
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Common goals at the end of life
• Be cured
• Live longer
• Maintain function/quality of life/independence
• Be comfortable
• Achieve life goals
• Provide support for family and caregiver
Goals toward the end of life: A structured review. Kaljian et al., 2009
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ACP AND SDM
Illness TIME Death
Lo
w
B
urd
en o
f ill
nes
s
Hig
h
adap
tati
on
HospitalHospital
MedicationMedication
Comfort Care vs. Hospital
Comfort Care vs. Hospital
Dialysis, Tests & ProceduresDialysis, Tests & Procedures
HospitalHospitalClinic visitsClinic visits
HospitalHospital
Clinic visitsClinic visits
Dialysis, Tests & ProceduresDialysis, Tests & Procedures
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ACP AND SDM
Illness TIME Death
Lo
w
B
urd
en o
f ill
nes
s
Hig
h
adap
tati
on
HospitalHospital
Comfort Care vs. Hospital
Comfort Care vs. Hospital
Dialysis, Tests & ProceduresDialysis, Tests & Procedures
HospitalHospitalClinic visitsClinic visits
Depression
Insomnia
Clinic visitsClinic visits
HospitalHospital
Dialysis, Tests & ProceduresDialysis, Tests & Procedures
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ACP AND SDM
Illness TIME Death
Lo
w
B
urd
en o
f ill
nes
s
Hig
h
Ad
apta
tio
n
Move to Asst. living
Move to Asst. living
No longer driving
No longer driving
HospitalHospital
MedicationMedication
Comfort Care vs. Hospital
Comfort Care vs. Hospital
Dialysis, Tests & ProceduresDialysis, Tests & Procedures
Caregiving help
Caregiving help
Sell HouseSell House
HospitalHospitalClinic visitsClinic visits
Depression
Anxiety
Insomnia
Clinic visitsClinic visits
HospitalHospital
Dialysis, Tests & ProceduresDialysis, Tests & Procedures
Caregiving help
Caregiving help
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41Shifting from Shared to Collaborative Decision Making: A Change in Thinking and Doing (O’Grady & Jadad, 2010)
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LifeCourse Team ACP/SDM Cues
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Summary Best Practice Late Life Care
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• Relationship continuum based care- Patient Driven
• Honoring patient goals, values and wishes- ACP
• Empower, Engage & Activate- SDM
• Proactive Support- Strength, Assets and Gaps
• Best Practice StandardsEducation and TrainingImprove Care experience and Quality of life