Objectives and Interventions for the End of Life Community in

Concord, North Carolina (28027)

Objectives

1. Throughout the community, there will be in increase in knowledge of end of life

services and utilization of these services to increase the quality of life in the end
of life community. This will be achieved by designing and implementing a
community outreach program that focuses on educating people about the benefits,
services for patients and families, referral criteria and dispel common myths
regarding end of life services. There will be an increase in the knowledge and
utilization of end of life services evidenced by a 15 percent increase in the total
number of hospice patient care for in 2011 when compared to 2010.
2. An increase in the quality of end of life care in the community will be achieved by
increasing the knowledge of the medical community regarding end of life care
and guidelines for making appropriate referrals to end of life care services. This
increase in quality of end of life care will be evidence by an increase in the
number of days on hospice services in the community from approximately 7 days
to 15 days within one year of initiating healthcare provider education and
outreach programs. In addition, a survey will be completed one year from
initiation of educational programs that will assess healthcare providers
understanding of hospice service and criteria for making appropriate referrals to
end of life programs. Fifty percent of healthcare providers surveyed will show
adequate understanding of these concepts.
The above objectives directly relate to Healthy People 2010's Goal 1 of increased life
expectancy and improved quality of life. It also addresses the objective of improved
health communication to inform and influence individual and community decisions that
enhance health. Although the focus of end of life care is comfort care rather than
improving health, improved communication by the healthcare community regarding end
of life care could greatly enhance the quality of life of the terminally ill. This goal
specifically states that good health communication can increase the demand for
appropriate health services and decreased demand for inappropriate health services. By
educating about service like hospice and palliative care, people can choose to utilize
comfort care measure rather than enduring painful often-unnecessary curative treatment,
which does not increase the quantity or quality of their life.

Intervention 1
Provide community education to end of life patients and families regarding Hospice
and Palliative Care of Cabarrus County services and other aspects concerning the
utilization of hospice and palliative care.

Rational: As indicated in the key informant interview with Janice Honeycutt, families
often write on their patient survey after a loved one’s death that they wish they would
have known about hospice and palliative care services earlier. Additionally, people
hesitate to attain hospice services because they feel this is the end of the road and that is
not a reality want to accept. To address this issue education sessions and presentations
are carried out by Hospice and Palliative Care of Cabarrus County, but these sessions
mainly focus on bereavement. Coney Rarey stated that the biggest issue related to the
utilization of hospice and palliative care is late referrals, she stated that “the majority of
the patients we care for are in the last year of their life and some in the last few days.”
She also mentioned that misconceptions about palliative care are also an issue. Patients
often think that palliative care means you are accepting hospice services as well and this
is not true. This is why patient education regarding the differences between the two
services is so important. To address this issue Coney Rarey stated that they are doing a
lot of patient education. Despite their efforts, the number of referrals received this past
year was no higher than that of 2008; therefore, it is hard to say whether patient education
is truly working.

Research is limited regarding the effects of community education on the utilization of

hospice services. However, research does conclude that quality of life and survival time
increases with the utilization of hospice. One study sponsored by the National Hospice
and Palliative Care Organization focused on the mean survival time between hospice
patients versus non-hospice patients. Evidence showed that patients who received
hospice services lived 29 days longer compared to those who did not. The study focused
on length of survival for a variety of different diseases and the biggest different in
survival between the hospice and non-hospice patients was observed in congestive heart
failure patients. In conclusion, there is a misconception among the American public that
hospice means you have given up, however research shows that hospice can not only
improve quality of life but also prolong life as well (Home Hospice, 2010).

A. Provide training to hospice and palliative care staff on services offered by Hospice
and Palliative Care of Cabarrus County, benefits associated with the care provide and
techniques for educating the public on hospice and palliative care services.

B. Educate healthcare staff in the community in particular those working at assisted

living centers, retirement homes, hospitals, and other agencies about hospice and
palliative care services.
• Provide fact sheets
• Hold information sessions
• Provide information in prescheduled meetings the facility is holding

C. Formulate a community outreach and education program, which includes staff of

hospice and palliative care, in the Cabarrus County area to educate residents about
hospice and palliative care services.

D. The staff of hospice and palliative care will increase public awareness about hospice
and clear up misconceptions of hospice services by:
• Visiting community retirement and assisted living centers and performing
presentations on hospice and palliative care services.
• Visiting community events and health fairs
• Creating posters appealing to the public with contact information to Hospice and
Palliative Care of Cabarrus County in which residents throughout the community
can ask questions about hospice and palliative care services. Post the posters in
healthcare facilities such as hospitals, doctor’s offices, outpatient clinics, health
departments, and living centers.
• Creating brochures listing information about hospice and palliative care and
clearing up any misconceptions about the services they provide. Make these
brochures accessible to residents by placing them in healthcare facilities such as
hospitals, doctor’s offices, outpatient clinics, health departments, and assisted
living centers.
• Holding forums at local senior centers and nursing homes to allow families and
residents to ask questions about hospice and palliative care and clearing up any
misconceptions associated with its services.

E. Collaborate with the cultural groups in the community to reach out to minority
groups. The community assessed was culturally diverse and large segments of the
population were made up of African Americans and Hispanics Americans, in addition to
the Caucasian population. In order to develop community outreach programs that will
increase the utilization of hospice and palliative care by these minority groups, it is
necessary to identify ways to reach out to and meet the needs of these individuals.
• Provide resources in a variety of languages, including brochures and
posters.
 • Have accessibility to translators when carrying out presentations and
informational sessions about hospice and palliative care services.
• Gain an understanding of these cultures beliefs and attitudes about death
and dying and how hospice and palliative care services can be
incorporated into these belief systems to improve quality of life during the
dying process.

F. Create support groups for family members and friends affected by death and dying
and provide information on how to care for loved ones.

Intervention 2:
Hospice and Palliative Care of Cabarrus County will create an educational program
to increase the knowledge of end of life services by healthcare providers, focusing on
physicians in the community.

A. A hospice nurses from Hospice and Palliative Care of Cabarrus County will visit
local community clinics, physician’s offices, and hospitals to provide in-service
education on the services offered by hospice and criteria for hospice eligibility.

The hospice nurse will hand out brochures outlining the following hospice services:
• Management of pain and symptoms of disease
• Education for caregivers/family of the hospice patient on providing care
• Assistance with activities of daily living and nutrition
• Provision of medical supplies and medications related to hospice diagnosis
• Counseling and social work services
• Assistance with funeral arrangement and bereavement counseling
 • Respite for families and caregivers

The hospice nurse will develop a booklet with guidelines on hospice eligibility for
physicians to use as a reference when determining if a patient should be referred to
hospice services. Guidelines from the National Hospice Organization include:

• The patient is expected to live six months or less. The condition is life limiting
and the patient/family are aware of this.
• The patient and/or family agree to treatment focusing on symptom relief as
opposed to a curative approach.
• There is documented evidence of disease progression, including physician
assessment, labs, and radiologic tests.
• Multiple ER visits or hospitalization over past 6 months.
• Recent decline in functional status, including dependence in 3 Bayer Activities of
Daily Living (BADL’s) or Karnofsky 50% or less
• Documentation of unintentional weight greater than 10% over six months
• Serum albumin 2.5 gm/dl

Rationale: A lack of education regarding hospice services and eligibility are barriers to
timely hospice referral. Physicians are referring patients to hospice service with only a
few days to live. According to the key informant Janice Honeycutt, the director of
nursing at Hospice and Palliative of Cabarrus County, the average number of days
patients in the community are on hospice services is less than two weeks. In-service
education on the services provided by hospice and eligibility criteria for hospice services
will decrease late referral by physicians. In addition, physicians will have a greater
understanding of the services provided by hospice and the criteria required for hospice
referral.

B. The hospice nurse will provide in-service education to physicians and nurses at local
hospitals on communicating with patients about end of life diagnosis, hospice referral
criteria and hospice services in order to increase physician referral to hospice. With
increased education and understanding, physicians are more likely to refer patients to
hospice at the earlier stage in the dying process. Physicians are the gatekeepers to
hospice, meaning that they are in a position to be the main referrers of patients to the
program. In addition, if nursing staff has a greater understanding of hospice care and
when it is appropriate for a patient they are able to advocate for the patient regarding
end of life care options.

• Hospice nurses and other healthcare team members can use a role-playing activity
during in-service education to facilitate discussion of end of life and the
possibility of hospice with patients. The role-playing activity would encourage
physicians and nurses to be honest and more comfortable with sharing news that
the patient may benefit from hospice services.
• The role-playing activity will follow a video that incorporates Robert Buckman’s
six-step protocol for breaking news to patients. This six-step protocol is used to
assist physicians communicate information regarding a poor prognosis to patients.
If physicians are comfortable discussing death and dying with their patients, they
may be able to present all care options that are appropriate including hospice and
palliative care options at an earlier stage in the disease process. This increase in
honest communication will provide patient with the information needed to make
appropriate healthcare decisions and would most likely increase hospice and
palliative care utilization

The six steps presented in the educational video:

• Starting-The physician will establish a comfortable physical setting with the
patient, use eye contact, and ask the patient who can be in the room.
• Ask the patient what information they already have been given on the hospice
program
• Find out how much information on hospice the patient wants at this time. By
asking the patient if they would like to hear more information on hospice, the
physician will identify if the patient is emotionally ready and open to the option of
hospice care at this time in their treatment. A patient who does not want to hear
 more information may be in denial and may either need more time to process the
prognosis.
• Give the information. Physicians can share their knowledge of hospice with the
patient. The physician can now present to the patient the information that they
have received from hospice workers about the program. This information will
include the purpose of hospice, who is involved in care, and Medicare eligibility
for hospice care.
• Respond to the patient’s feelings and questions about the hospice option. The
physician needs to be sensitive and understand that the patient may still have
feelings of hesitation and fear regarding hospice. By asking the patient how they
are feeling at this time, the physician can possibly alleviate patient anxiety about
the program.
• Plan and following up If the patient expresses interest in entering hospice, the
physician should now contact the hospice representative and collaborate with the
representative on forming a plan for future patient care.

After the video, the hospice representative will present a case study of a terminal patient
and conduct a role-playing activity in which the physicians can utilize the six steps
presented in the video to begin communication of the hospice program with the “patient”.

Rationale: By providing education on therapeutic discussion of terminal diagnosis and

hospice care, physicians will feel more comfortable and competent in referring patients to
the hospice service. With increased comfort in discussing the terminal diagnosis and
hospice with patients, the physician will be more likely to discuss the option of hospice
care at an earlier time in the diagnosis. In addition, if nursing staff has a greater
understanding of hospice care and when it is appropriate for a patient they are able to
advocate for the patient regarding end of life care options. As a result, average days on
hospice service can increase from 7 days to 15 days.

C. The local hospital will utilize an independent liaison trained and knowledgeable in
hospice and palliative care referral criteria and local hospice and palliative care
services to assist healthcare providers in the hospital setting identify patient that are
appropriate for referral to hospice and palliative care. Preferably, this liaison would be
a palliative care physician in order to facilitate peer-to-peer education, but a palliative
care or hospice nurse would be appropriate as well.

• Hospice and Palliative Care of Cabarrus County will assist Carolinas’ Medical
Center Northeast identify a palliative care physician or hospice nurse that is
willing and enthusiastic about improving hospice utilization. This person will be
on call to assist healthcare providers to review patient’s medical history and
current condition to determine if the patient’s condition is appropriate to refer to
hospice and palliative care services.
• The physician will then be a resource for fellow physicians to consult on the
concept of hospice.
• Fellow physicians may be more open to learning about hospice from a direct
peer.

Rationale: With the establishment of a palliative care physician, physicians at the

hospital and in the community will be better educated on hospice service and have the
advantage of prompt answers to concerns and questions about hospice service and
eligibility of patients. With increased knowledge of hospice services, the physician will
be able to refer patients to hospice care at an earlier time.