C.A.R.E
Four agencies began working together over three years ago to develop a
Palliative Care Program in our community..
They are:
1. First Light Health Systems (formerly Kanabec Hospital and
Allina Clinic)
2. Kanabec County Public Health
3. The Villa Health Care Center
OUR MISSION
Provide resources to empower individuals to meet their needs and
support relationships with family, care providers and the community.
COMMUNITY NEEDS
ASSESSMENT
We began to work on a survey to identify the needs of our community.
This effort was spearheaded by a member of our group from the Villa
who was doing a project for her DNP-Mary Wotzka Laagard.
We found that patients overriding concerns were pain control, autonomy
and
maintaining function.
ENTER STRATIS
In the fall of 2009 we applied for and were granted by Stratis the
opportunity to be involved in their grant….We were excited!
After our visioning day we identified the top priorities for our group
TOP NEEDS/GOALS
Three most important things committee wants to accomplish with this
project:
Excellent Patient care, focused on Patient-identified goals and needs.
Implement a community based, hospital housed palliative care program.
Educate staff and community
Community involvement and increase collaboration across organizations.
PROJECT ACTION
PLAN OBJECTIVES
Provide introductory education/training on
palliative care to at least 50% of health care
professionals in the four participating organizations.
Advanced Care Planning: Roll out common
advanced directive planning process/attend
Honoring Choices Conference and to have a
certified trainer
Develop a common palliative care order set/care
plan that can “travel” with the patient across settings
Provide patient and community education
OUR VISION
Hospital housed: Hospital is lead organization with most available
resources
Community based: Use multiple community resources
Rural: ??
Collaborative
Currently resources can be fragmented
Silo affect
Fiscal Responsibility
Best utilization of our current community resources without
additional financial responsibilities
OUTCOMES
Number of palliative patients
Potential of 79 in year 1 (Per Center to Advance Palliative Care calculator)
Success measured by 20% in year 1which is 16 patients
COMPONENTS
MD
Primary MD
Support of order sets
Phone Calls
Hospital
Maintains a list of all palliative care patients
Calls screened by hospital nurse with specific protocols based on care plan and order sets
HOW DO WE
IDENTIFY
PATIENTS?
Nurse
Physician
Community Partners
Social Services meet with patient to discuss/assess palliative care options and criteria
Connect with:
MD/Care Provider
Community Resources
CARE PLAN
Multidisciplinary
Initial Paper Documentation
Reflects Model of Acceptance
FURTHER PLANS
Have had the added support of an R-pap student and Pharmacy Resident.
We have taken the Program to our Ministerial team and they are ready to
be involved.
We are looking at spiritual assessment
SUPPORT
We do have a Physician Champion: Dr. Joe Lind
He has brought our program to medical staff to gain support and to aid in
communication with other providers regarding where the program is
headed.
WE GOT ONE!! ( ok, now three)
We took the leap and approached a patient whom Dr.Lind felt would be
a good fit and he was interested.
We have had several phone contacts and one visit with him to complete
his Advanced Care Plan.
We also approached a female who was willing to be involved and are now
working on our third and fourth patient!!!