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Mini-CHAMP Part I: Hospice and Palliative Care--the Idea & the Medicare Benefit Part II: Teaching how to “Break Bad News”.


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Mini-CHAMP Part I: Hospice and Palliative Care--the Idea & the Medicare Benefit Part II: Teaching how to “Break Bad News”. Seema S. Limaye, MD University of Chicago. Part I : Hospice and Palliative Care--the Idea & the Medicare Benefit. Part II : Teaching how to “Break Bad News”.
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Small scale CHAMP Part I: Hospice and Palliative Care- - the Idea & the Medicare Benefit Part II: Teaching how to "Break Bad News" Seema S. Limaye, MD University of Chicago

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Part I : Hospice and Palliative Care- - the Idea & the Medicare Benefit. Part II : Teaching how to "Break Bad News". Area of Geriatrics September 8, 2008 Mini-CHAMP Lecture Series

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Goals Understand hospice and palliative consideration administrations and the Medicare advantage. Distinguish more seasoned grown-up patients for whom hospice consideration is fitting. Talk about hospice care with more seasoned grown-up patients and their families. Educate successful relational abilities to restorative understudies and inhabitants to run family gatherings

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Hospice center is on agony and side effects administration understanding has a terminal determination with future of under six months not looking for remedial treatment Palliative Care center is on torment and side effect administration quiet does not need to be terminal may at present be looking for forceful treatment Comparing Hospice versus Palliative Care

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How are hospice and palliative consideration comparative? Center is on personal satisfaction of the patient. The objective for both sorts of consideration is to deliver any acclimation to ailment or end-of-life issues.

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Medicare Hospice Benefit To get this advantage bundle, a patient needs to join – assigning the greater part of their Part An advantages including care identified with their essential terminal analysis over to the hospice office

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What is incorporated into this benefit The hospice group – RNs, SW, minister, supervision of a hospice doctor, Nurses Aids up to 1-2hrs day by day, volunteers (as a rule 3 hrs a wk), and deprivation support for up to 13 months after Medications/treatments for the sole reason for whitewashing of side effects identified with the essential conclusion Medical gear for security/side effect alleviation Dressings/other care needs identified with the determination 24 hr scope

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Where can hospice be drilled? Keep in mind, hospice is a reasoning—to give poise and solace when the patient has a terminal diagnosis(es). Home NH Hospice houses Inpatient hospice units

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Various levels of consideration Routine home consideration/nursing home at middle of the road nursing level Respite care – up to 5 days a month rest for family, with patient in a nursing home – food and lodging and minded paid by the hospice Continuous Care – 8 – 24 hrs of consideration a day, half of which is finished by a RN/LPN, just accessible with a gifted need – forceful side effect control, intense unsettled state, quick physical change. The need is assessed day by day

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Various levels of consideration (cont) In-patient Hospice – For patients who need forceful side effect alleviation requiring nonstop observing. This is normally just for up to 5-7 days. On the off chance that patient balances out, another setting should be found. The expense of this is paid by the hospice by means of Medicare

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Do patients/families surrender by marking the advantage? While in hospice it is exceptionally hard to do forceful life-drawing out consideration; however we do forceful solace care! They can simply sign out of the advantage at whatever time to seek after more life-dragging out consideration, without punishments They can keep on seeing their specialists Medicare will pay for optional judgments care, i.e.: dialysis for long-standing renal disappointment You can't be in a SNF for recovery and in hospice in the meantime

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What about different protections? Medicaid takes after Medicare conventions; repayment is comparable Private protections/HMOs have a tremendous extent relying upon every individual arrangement – from NO hospice scope, to a $3000 limit (around 20 days), for a full scope with boundless in-patient stay and more forceful treatment arranges paid for independently

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Common Hospice Misconceptions The patient must be disabled keeping in mind the end goal to be qualified for hospice care. Hospice advances QOL and capacity! The patient must have malignancy. Being on hospice implies surrendering trust. Help patients and families re-outline their trust.

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Common Hospice Misconceptions (cont) 4. I should be "DNR" to agree to hospice. 5. I lose control/access to restorative consideration on the off chance that I agree to hospice. 6. I can't dis-enlist from hospice on the off chance that I alter my opinion or show signs of improvement. 7. It's "too soon" for me to agree to hospice. - If patient is restoratively fitting for hospice, concentrate on the additional bolster they will get at home, and enhanced personal satisfaction due to side effect control.

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So who ought to get palliative consideration administrations? Patients with manifestations identified with incessant diseases who may at present be looking for forceful treatment. The attention is on torment and non-torment side effect administration. Start discussions about patients' objectives of consideration, comprehension these may changes as ailment advances/dispatches.

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In-home palliative consideration expanded patient fulfillment and decreased utilize and expenses of medicinal administrations Design: Randomized, blinded controlled trial. Follow-up period: Death or end of study period. Setting: 2 HMOs in Hawaii and Colorado, USA. Patients: 310 patients (mean age 74 y, 51% men) who had an essential determination of congestive heart disappointment, interminable obstructive aspiratory sickness, or malignancy; had a future   < 12 months; had gone to the crisis office or doctor's facility inside the earlier year; and scored  70% on the Palliative Performance Scale. Brumley R. et al.Increased Satisfaction with consideration and brought down costs: consequences of a randomized trial of in-home palliative consideration. JAGS; 2007;55;993-1000.

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IHPC Study Intervention: IHPC in addition to common consideration ( n = 155) or regular care alone ( n = 155). Doctors directed home visits and were accessible, alongside nursing administrations, on a 24-hour available to come back to work premise. Normal consideration: took after Medicare rules for home social insurance criteria to give different sums and levels of home wellbeing administrations, intense consideration administrations, essential consideration administrations, and hospice care.

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Outcomes/Results Pt Satisfaction: IHPC superior to anything UC at 30 and 90 Days (93% versus 80%) Cost: IHCP less expensive than UC ($12,670 versus $20,222) ER visits: IHPC versus UC (20% versus 33%) Hospital Admissions: IHPC versus UC (36% versus 51%) Death at home: IHPC versus UC (71% versus 51%) Life hope: IHPC versus UC (196days versus 242 days)

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Palliative Care Services Offered at Home Initially, a doctor or APN visits the patient at home to survey manifestation control and objectives of consideration. Patient is assessed about like clockwork for side effect administration. Interdisciplinary Pall Care group: may incorporate SW, pastor, APN, MD to consider Pt to be required. Pall care group can move patients to hospice if illness advances, objectives of consideration change. Additional home nursing or CNA administrations gave on sliding scale expense to benefit.

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Continuum of Care Bereavement Care Hospice Disease adjusting therapeutic treatment *Curative, life-drawing out, or palliative in plan Palliative Care *Symptom control, strong consideration Illness Death

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Palliative Care Reimbursement There is no repayment coordinated to this yet Right now, just the doctor or propelled medical attendant experts charging under their standard claim to fame for manifestation determination is repaid. Rest of consideration is charged under their standard Medicare/protection – i.e.: part D for meds, home tend to helps/RNs Some healing facilities do their in-patient consideration under this, charging for the DRG for the conclusion outside of hospice

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Communicating Bad News Not generally instructed in restorative training. Learners frequently refer to perception as just related knowledge they get before having to "break terrible news" all alone. As of now 3 rd year Pritzker understudies have 1.5hr workshop to figure out how to break terrible news.

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Challenge So how would we instruct these essential relational abilities considering the time-crunch we as a whole face? Rehearse! Devise "course of action" before the meeting: educate the SPIKES mnuemonic Supervise beginning family meeting

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6 Steps/"SPIKES" S et up the meeting Find out what the patient knows ( P erception) Find out what the patient needs to know ( I nvitation) Give data ( K nowledge) Respond to the patient's feeling ( E movement) Closing ( S ummarize/Support) Baile WF. Buckman R. Lenzi R. Glober G. Beale EA. Kudelka AP. SPIKES-A Six Step Protocol for Delivering Bad News: Application to the Patient with Cancer. The Oncologist 2000;5;302-311.

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1. Setting Prepare yourself (prepping, information, pager… ) Prepare the room (security, seats, tissues) Gather others patient may need there Make eye contact Appropriate non-verbal communication Adequate measure of time

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2. Observation "What is your comprehension of what is going on as of now with your therapeutic circumstance?" Knowing patient's level of cognizance empowers you to begin at suitable point. Can prematurely end process on the off chance that it seems more is required (relatives, other backing).

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2. Observation, cont'd. Dialect Barriers: Use a medicinal translator, NOT family Speak to the patient

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3. Welcome "If the consequences of your tests were not kidding, do you need us to converse with only you, or are there others you would need present?" "The amount of your restorative condition would you like to talk about?"

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3. Welcome, cont'd. Consider the possibility that family requests that you not examine discoveries with the patient. Morally & lawfully committed to talk about with patient what they need to know, and who else they need information examined with. Best to do this before family.

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4. Information Give cautioning shot! Use dialect the patient will see (no medicinal language). Stop habitually to check for comprehension ("Is the thing that I am stating making sense?"). Little measures of data at once. Take into account hush! Use fitting non-verbal communication, eye contact. Maintain a strategic distance from dubious terms ("tumor", "mass", "irregularity")

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4. Information, cont'd What in the event that they request forecast? Just answer on the off chance that you are agreeable/reas