Running Head: CARE COORDINATION FOR WHATCOM HOSPICE PATIENTS

Care Coordination for Whatcom Hospice Patients

Kathleen Minor
Western Washington University

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The practice experience site visited this quarter is Whatcom Hospice and its twelve bed
Hospice House. Hospice care is available to persons with a terminal or life limiting illness,
whose primary care provider has determined their life expectancy to be six months or less.
Almost all enrolled patients receive Medicare services, where Medicare not only funds the cost
of hospice but dictates program requirements for patient and family care. Hospice care is not
exclusively for geriatric patients. Patients range in age and may have any number of conditions
such as dementia, metastatic cancer, heart disease or COPD.
Since Whatcom Hospice is a Certified Medicare Services (CMS) program, CMS
specifically defines a qualifying condition and criteria for a patient to be eligible for hospice
care. Qualification requires the hospice team to provide Medicare with proper documentation
regarding the terminal condition. The team consists of a medical director, admissions personnel,
registered nurses, nurse case managers, social workers, chaplains, home health aides and
volunteers who offer many different services from quilt making to transportation. The hospice
team aims to provide the patient and family with the most comprehensive, holistic care possible.
Comprehensive care includes treatment and support of physical, spiritual, and end of life care
planning needs as well as providing any medical equipment or medications considered suitable
for the patient.
Care Coordination Models
Hospice does not follow one specific care coordination model, but rather utilizes aspects from
several different models. Specifically, Hospice incorporates aspects from both the Care
Transitions Coleman Model and the Transitional Care Naylor Model (Lamb, 2013). Below is a
table that illustrates aspects found in each model regularly used in Hospice care.

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Goals

Care Transitions Coleman

Model

Transitional Care Naylor

Model

Reduce rates of rehospitalization

Reduce rates of rehospitalization

Increase patient confidence

during transition and beyond

Reduce ED visits for primary

and co-existing conditions

Encourage the patient and

caregiver to assert a more
active role during care
transitions

Reconcile and manage

medications

Use a patient-centered health

record to guide patients
through the care process

Enhance patient and family

caregiver satisfaction
Reduce total health-care costs

Understanding of red flags:

and appropriate next steps

Staffing

Care Transitions Coleman

Model

Transitional Care Naylor

Model

Nursing/Transition Coach

Transitional Care Nurse

*Someone with strong

interpersonal skills, the ability
to make the shift from doing
things for patients to
facilitating skill transfer so
that patients can do more for
themselves

On call seven days per week

*Home visits and telephone
access for one to three months
of home follow-up

Literature Review
Cinahl database was used to research the above stated care models, where it was found
that their development was a result of the massive costs incurred by Medicare and Medicaid
related to hospital readmission rates and the need to identify ways to curb these costs. (Decoster,

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V., Ehlman, K., & Conners, C. (2013). Colemans theory identifies a transitions coach as a key
element of the model (2002) which resembles the hospice admissions process. As Coleman
indicates, the transitions coach can be a nurse or another discipline. At Whatcom Hospice, often
the Medical Social Worker (MSW) is the individual who first meets with patients and families to
discuss the role and philosophy of hospice care, this is especially true if the hospital has referred
the patient to Hospice. The hospice medical director is then consulted and reviews patient
records to determine eligibility. The MSW, along with hospital and community based providers,
coordinate the hospital discharge and the subsequent hospice admission; often ordering durable
medical equipment, interfacing with the nurse who will first be visiting the patient and family in
the home or other care setting. The MSW then transfers the case to the community hospice team
who takes over as transition coaches. In the hospice model as described by Medicare, the nurse is
the case manager and is to coordinate the overall care of the patient and family with their goals
being at the center of how care is delivered.
Care Map
The patient I selected to follow at Whatcom Hospice is a 27-year-old male with a recurring brain
tumor, specifically an Anaplastic Astrocytoma who currently resides at the Hospice House due to
extensive medical and physical needs. The patient is on a continuous Fentanyl infusion, has
become mostly nonverbal, is incontinent, has a PEG tube for feeding, and must be turned every
two hours to prevent skin breakdown. Unfortunately, this is not the patients first brain tumor and
was diagnosed and treated with radiation therapy for a Medulloblastoma at age three. Although
unsure, the patients oncologists feel that his aggressive radiation treatment at such a young age
may have contributed to the reoccurrence of his current brain tumor. The effects of his current
brain tumor on the rest of his body include left sided palsy with generalized muscle spasms and

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spasticity. The patients ability to verbally communicate is altered and alertness is inconsistent,
therefor he uses a white board for yes/no communication. Although at times of great muscle
spasticity, the patient is unable to communicate using the white board and requires careful
assessment and anticipation of needs using a nonverbal pain scale and other physical cues.
The following care map was designed to tailor the needs of this specific patient. At the center of
the care map lies both the patient and family. Providing care not just for the patient but for the
family is an important goal of Hospice, and considering the young age of the patient and the
degree of his illness, providing supportive services to family members is included in care.
Encompassed around the patient and family in the center is the concept of providing comfort
care, which all other aspects and branches illustrated in the care map work together to achieve
for both the patient and family.
Key components for this patient and family are found in the care map. While at hospice house,
the patient is monitored 24/7 for needs and receives continuous assessment and symptom
management on an immediate level coordinated by nurses and physicians. To provide extra
comfort, the patient has received gentle massage from certified volunteers as well as visits from
physical therapy to aid with muscle spasticity. The family identifies as Christian, and benefits
from chaplain visits which include prayer and a review of the patients life.
The patient and immediate family members (younger brother and mother Beth) are currently
estranged from the patients father, circumstances unknown. Both the patient and family have
expressed that no information may be disclosed to the father unless given permission. Both the
patient and family have expressed no desire for the father to visit or be included in the patients
care. So far, the father has respected family and patient wishes and no conflict has been noted.

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The patient has had a longtime friend who is encouraged by both family and staff to visit when
available, which provides the patient with peer social support.
Patient family members spend long hours at the hospice house with their loved one, and
volunteers prepare snacks for the family members as well as provide light housekeeping at their
residence once every two weeks. The patient has a very low BMI and becomes chilled easily.
One volunteer made a blanket for the patient to provide extra comfort in his favorite colors, blue
and yellow.
The durable power attorney and primary care provider Beth, the patients mother, is debating on
whether to bring her son home in order for him to die in a familiar setting. The patient has
currently resided at hospice house for the past 45 days, with his overall health and cognitive
function declining over the past year. As indicated by a star shape in the care map, the areas
marked have been discussed with the patient and family as services available if they so choose to
remove him from the Hospice House. All other resources found on the care map will continue to
be available for the patient and family.
No parent imagines outliving their children. Information on local and national support groups for
grieving parents and siblings have been discussed by hospice staff. 13-month bereavement
support including home visits, phone calls, and check-ins will be especially important for this
family after their loved one has passed.

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Plan of Care

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Smart Goal: Patients mental and physical status continues to decline. Patient is now bedbound,
and cannot consistently communicate using the whiteboard. After further discussion with patient
and mother, it was determined that goals in patient care have shifted. The patient will remain at
Hospice house to receive 24/7 care until end of life, considering his high acuity and care needs.
Based on the patients prognosis, his insurance will continue to cover his stay at Hospice house
until end of life. The following addresses patient problem areas, goals, and subsequent
interventions.

A. Problem: Alteration in communication

-Goals: Keep patient content/comfortable by adequately assessing patient needs.
-Interventions: White board for yes/no communication, frequent assessments and anticipate
patient needs, use FELDT scale to assess pain.
B. Problem: Anxiety
-Goals: no signs/symptoms/statements of anxiety
-Interventions: calm environment, frequent brother and/or mother visits, prn and scheduled
Ativan.

C. Problem: Persistent head and neck pain

-Goals: Pain managed, under 3/10 pain using FELDT scale and yes/no white board
communication.
-Interventions: Fentanyl infusion, repositioning, elevated HOB to decrease intracranial
pressure.

Evaluation

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The plan of care designed for this young hospice patient successfully identifies high priority
problems, sets reasonable goals of care and provides practical interventions to achieve the
highest level of comfort care possible. By choosing to remain at Hospice house, the patient
and family benefit from immediate hands on interventions when symptoms worsen versus a
greater time lapse in symptom management in the home setting. In addition, the family is
able to spend quality personal time with their loved one instead of acting as the primary care
giver. Although the patient experiences episodes of break through pain and anxiety, the
family feels that his care is being greatly managed in the inpatient setting.

References

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10

Coleman, E. A., Smith, J. D., Frank, J. C., Eilertsen, T. B., Thiare, J. N., & Kramer, A. M.
(2002). Development and testing of a measure designed to assess the quality of care
transitions. Int J Integr Care International Journal of Integrated Care, 2(2).
doi:10.5334/ijic.60
Decoster, V., Ehlman, K., & Conners, C. (2013). Factors Contributing to Readmission of Seniors
into Acute Care Hospitals. Educational Gerontology, 39(12), 878-887.
doi:10.1080/03601277.2013.767615
Lamb, G. (n.d.). Care coordination: The game changer: How nursing is revolutionizing quality
care.