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by Janice Lynch Schuster
A dozen Pittsburgh-area nursing homes applied a rapid-cycle quality improvement strategy to improve care for dying residents and their loved ones. The Pittsburgh End-of-Life Collaborative (PELC), led by The End of Life Providers Task Force, the Faith Based Network, the Center for Palliative Care Studies, and the University of Pittsburgh Health Institute, brought together teams from the Pittsburgh region to identify and solve common problems. A team of experts in quality improvement and geriatrics, under the the leadership of Nicole Fowler, M.P.H., of the University of Pittsburgh, and Anne Wilkinson, Ph.D., taught participating groups to use the rapid-cycle approach to health care improvement. (For more on this, see "Improving Care for the End of Life," and visit: http://www.medicaring.org).
Although new federal programs require nursing homes to introduce quality improvement strategies, little is known about the quality of end-of-life care in nursing homes. However, many studies indicate that pain management, continuity of care, and family satisfaction are significant problems for most nursing homes nationwide. Through the QI process, Pittsburgh area teams looked at particular problems in their own settings, and then set about solving them.
Participants found unique ways to deal with common problems. This article describes just four whose experiences and results might inspire others to act-NOW-to improve.
Mollie's Meals. Meals-on-Wheels programs have become so popular that most of us wouldn't see them as an opportunity to improve end-of-life care. But Bayla Butler, who directs Mollie's Meals in southwestern Pennsylvania, found that its services were a way to open the door to many frail and sick adults. "Meals are not our sole function," Butler said. "Meals are just a way to get our foot in the door. Most of our clients need an array of services, and this is one easy way to assess other needs and provide those services."
Mollie's Meals, affiliated with the Jewish Association on Aging, delivers kosher meals to more than 100 people, regardless of faith. During Phase One of the QI project, Butler aimed to reduce and prevent falls to reduce institutionalization among vulnerable clients. In the study group, changes were assessed and made within one week. Only one client in that group was later hospitalized after a fall, compared to 36% of the clients in the control group.
As the project continued, Butler added a self-report and psychosocial assessment to the home safety assessments, aiming to address psychosocial issues as a way to keep clients healthier and connected to the community. Mollie's Meals began to include a two hour visit with a social worker to talk to clients and assess needs. This approach found that 60% of clients said that they were depressed; of these, 75% had no one to depend on in an emergency. To reduce clients' sense of isolation, volunteers were recruited to make twice weekly phone calls to check in with clients, discuss menu choices, and offer a friendly voice. According to Butler, the program now aims to strengthen the community's involvement with homebound elders.
Presbyterian Senior Care looked at ways to improve practices on the dementia unit of this 200-bed facility. Linda Coulter, BSN, assistant director of nursing, said that the team decided to focus on reducing unnecessary hospital transfers among patients who were in the final two weeks of life. "We felt that some residents who were being transferred could have been managed [in the nursing facility]," Coulter said. The team studied symptoms that led to transfers, and reviewed which floors and shifts seemed to have the largest number of transfers.
"It's not that we felt we were totally out of line," Coulter explained. "But we began to believe that even one unnecessary transfer was unacceptable."
A major step involved improving pain management and other symptom control for dementia patients near the end of life. The team reviewed the types of pain medication kept on site, and began to keep drugs on-site to help with symptoms such as breathlessness, nausea and vomiting. Treating these problems in the nursing home enabled the group to reduce hospitalizations.
The team also began to work more closely with a hospice program to provide better end-of-life care, and to educate staff and family members about the disease process for patients with dementia. The process now includes checklists, which are reviewed with family members, and regular family conferences to discuss what is happening.
"With dementia patients, it is very hard to see what the symptoms are because patients experience such a slow decline," Coulter said. With the checksheet, families were better able to understand what was happening and why, and to avoid panicking or insisting on hospitalization.
To help staff and other residents honor those who died in the facility, the QI team created a Memorial Moment, a small tribute held within 24 hours of a resident's death. A fresh white sheet is placed on the bed, along with a small bouquet of flowers. Staff, family, and residents are invited to gather to talk about the loved one's life and share memories. "At first, these moments were stiff, but now we find humor and meaning," Coulter said.
Villa St. Joseph, a 120-bed nursing home, worked to increase the number of families who understood that a loved one was near the end of life, in part by better understanding the nature of the diagnosis and the symptoms that accompanied it. The team taught families that were faced with end-stage renal disease by working with staff. A key step was to work with attending physicians to identify which patients were terminal and to ensure that all staff understood the diagnosis before approaching the family. The process of identifying patients who were likely to die allowed the team to approach families with information about the disease and relevant end-of-life concerns.
The team enlisted the help of a local hospice program to provide support and information to families. According to administrator Mary Murray, this outreach to hospice was the first time the nursing home had developed a consistent, close relationship with an area hospice. In the past, turf issues stymied collaboration. "Once our staff realized that they were on the same page as hospice, they realized that they had common goals," said Peggy Cooper, director of staff development.
A key goal was to improve pain management for patients with Alzheimer's disease. The team worked with staff to raise their awareness of chronic pain in elderly patients and how to address that pain. "We soon realized that we really needed to work on pain for every patient," Cooper said.
The team struggled with ways to measure progress because it was working to change perceptions and perspectives. With help from the QI leaders, the team decided to identify markers for progress, such as whether or not families wanted aggressive treatment and intervention for loved ones who were near death.
Concordia Lutheran Ministries wrote a headline to describe its project: "Pain Free and Never Alone." To improve pain management for patients with Alzheimer's and other dementias, the team asked staff to track other signs of pain, such as yelling, grimacing, changes in eating or walking, and to track these signs on grids. Patients were treated for pain-and the number of pain-related symptoms fell from an average of fifteen to three per patient. As a result of this successful endeavor, the team now recommends that all new patients be assessed. Patients who are not able to communicate are also assessed and evaluated on a quarterly basis.
The Concordia team also addressed the issue of people dying alone; most adults state that they fear dying in a nursing home or dying alone. Staff were troubled by how often patients died in just this way. The team created a volunteer program to recruit others in the Concordia community (a continuous care community) to sit with dying patients. These "Angels on Call" stay with people who have no family, or whose families cannot get to the nursing home. Volunteers participate in a six-week orientation session so that they feel "confident and ready to comfort."
As one team member put it, "It's easy to develop programs for people who want bingo and cards games. At the end-of-life, what to do and how is harder to figure out."
To participate in a quality improvement collaborative, consider joining a new national effort scheduled to begin in January. Learn more at:
http://www.medicaring.org/nc2004/
For more information on programs discussed, contact the following:
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