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Palliative Care Advance Care Planning A Collaborative Approach Sheldon Lewin MSW,MBA
Program Goals ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Medical Therapy Choices ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
People Care  About ,[object Object],[object Object],[object Object],[object Object],[object Object]
Definition- Palliative Care: ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Palliative Care Components ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Palliative Care Intake Screen
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Assess  Psychosocial Needs &  Provide Support
Assess Psychosocial Needs ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Psychosocial Support ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Advanced Care Planning Facilitate ACP Meeting
Advance Care Planning:  Issues or Conflicts ,[object Object],[object Object],[object Object]
Advance Care Planning:  Values & Beliefs ,[object Object],[object Object],[object Object],[object Object],[object Object]
Advance Care Planning:  Advance Directives ,[object Object],[object Object]
Advance Care Planning:  Family Conference ,[object Object]
ADVANCE DIRECTIVES
Advance Directives ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Advance Directives ,[object Object]
Advance Directives ,[object Object],[object Object],[object Object]
Advance Directives ,[object Object],[object Object],[object Object]
Advance Directives ,[object Object],[object Object],[object Object],[object Object]
CHMC-Advance Directives Process   1.  ACCESS CARE Patient admitted to hospital Access Care  staff provides the patient an  Advance Directive  form and packet of information including copy of  “Your Right to Make Decisions about Medical Treatment” and asks if patient has a completed  Advance Directive   Access care staff checks appropriate box in Condition of Admission (COA) and Treatment (Part 1) form End Patient is admitted to hospital Does patient have an  Advance Directive ? No Yes Copy available? No Access care staff sends copy to nursing unit Yes  1. Patient wishes additional information  2. Patient is  unable to  receive  information  regarding  Advance  Directive
CHMC-Advance Directives Process   2. NURSING/SOCIAL SERVICES Patient admitted to room Nurse Nurse Nurse reviews the Condition of Admission (COA) & Completes  Interdisciplinary Intial Assessment   (Checks and signs Advance Directive section) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Nurse Social Worker
Advance Directives  Patient Information & Education   Sobre Instrucciones Medicas Anticipadas Available in Spanish & English Contact Social Services  at x5560 or  via AS400
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Advocacy &  Referrals
  Who Can Benefit?
  Who Can Benefit?
Who Can Benefit?
Who Can Benefit?
Who Can Benefit?
Patient & Family Education
Patient Education ,[object Object],[object Object],[object Object]
Palliative Care  & the Chaplain’s Role 1 .   Assess patient’s spiritual needs 2.  Provides grief and bereavement  support 3.  Document interventions 4.  Attend family conference
[object Object],[object Object]
Spiritual Needs  Assessment& Support ,[object Object],[object Object],[object Object]
Grief & Bereavement Support
Grief & Bereavement ,[object Object],[object Object],[object Object],[object Object]
Palliative Care & the Case Manager’s Role 1.  Assess patient’s discharge needs 2 .  Coordinate and document  referrals to hospice or home health, DME 3.  Patient Satisfaction.  Preparing patients to deal with pain at home.  4.  Attend family conference
Discharge Planning & Home Health/  Hospice Care Referrals
Referrals to Home Health Hospice, LTC, SNF, etc ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Palliative Care &  the   Physician’s Role     1.  Discuss and  document patient’s options for treatment 2.  Discuss and  document options for pain and symptom management 3.  Ensures consensus is reached among physicians 4 . Certifies that the patient needs the services provided and agrees/signs plan of care 5 . Attend family conference

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Palliative Care Advance Care Planning A Collaborative Approach

  • 1. Palliative Care Advance Care Planning A Collaborative Approach Sheldon Lewin MSW,MBA
  • 2.
  • 3.
  • 4.
  • 5.
  • 6.
  • 8.
  • 9. Assess Psychosocial Needs & Provide Support
  • 10.
  • 11.
  • 12. Advanced Care Planning Facilitate ACP Meeting
  • 13.
  • 14.
  • 15.
  • 16.
  • 18.
  • 19.
  • 20.
  • 21.
  • 22.
  • 23. CHMC-Advance Directives Process 1. ACCESS CARE Patient admitted to hospital Access Care staff provides the patient an Advance Directive form and packet of information including copy of “Your Right to Make Decisions about Medical Treatment” and asks if patient has a completed Advance Directive Access care staff checks appropriate box in Condition of Admission (COA) and Treatment (Part 1) form End Patient is admitted to hospital Does patient have an Advance Directive ? No Yes Copy available? No Access care staff sends copy to nursing unit Yes 1. Patient wishes additional information 2. Patient is unable to receive information regarding Advance Directive
  • 24.
  • 25. Advance Directives Patient Information & Education Sobre Instrucciones Medicas Anticipadas Available in Spanish & English Contact Social Services at x5560 or via AS400
  • 26.
  • 27. Advocacy & Referrals
  • 28. Who Can Benefit?
  • 29. Who Can Benefit?
  • 33. Patient & Family Education
  • 34.
  • 35. Palliative Care & the Chaplain’s Role 1 . Assess patient’s spiritual needs 2. Provides grief and bereavement support 3. Document interventions 4. Attend family conference
  • 36.
  • 37.
  • 39.
  • 40. Palliative Care & the Case Manager’s Role 1. Assess patient’s discharge needs 2 . Coordinate and document referrals to hospice or home health, DME 3. Patient Satisfaction. Preparing patients to deal with pain at home. 4. Attend family conference
  • 41. Discharge Planning & Home Health/ Hospice Care Referrals
  • 42.
  • 43. Palliative Care & the Physician’s Role 1. Discuss and document patient’s options for treatment 2. Discuss and document options for pain and symptom management 3. Ensures consensus is reached among physicians 4 . Certifies that the patient needs the services provided and agrees/signs plan of care 5 . Attend family conference