Running head: A CARE COORDINATION MODEL

A Care Coordination Model for Hospice Patients

Michelle Carrillo
Western Washington University

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Introduction

The practice experience site that I am at is Whatcom Hospice located in Bellingham,

which is a community based program and also has a 12 bed in-patient hospice house. This paper
focuses on patients that are currently part of the Whatcom Hospice program. Hospice care is for
individuals of all ages who are nearing the end of their life and are expected to live no longer
than six months, as deemed by their care provider. Hospice provides end of life care that is
delivered by the Registered Nurse (RN) to patients in their homes or at the hospice house.
Eligibility for patients to be on hospice is determined by the patients appointed physician,
primary care provider.
Whatcom Hospice is a Medicare Certified Hospice program, therefore, the Center for
Medicare Services (CMS) governs the standards for care at Whatcom Hospice, as well as
determining the criteria that patients must meet to be eligible for this program. Other criteria that
must be met for Whatcom Hospice as set forth by CMS consists of an interdisciplinary care team
which includes a Medical Director, Medical Social Worker (MSW), Home Health Aide (HHA),
Chaplain, RN, as well as volunteers. CMS describes the hospice patient as being the patient
and family, so it is expected that the patient and family will be treated and cared for as a unit
once they are in the hospice program as this is holistic care supporting physical symptoms,
spiritual distress, and planning care for the end of life. CMS requires an appointed member of the
interdisciplinary team to meet with the patient within five days of admission, but the patient can
refuse this.

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Care Coordination Model

In reviewing care coordination models for the purpose of this paper, there are two models
closely aligning with Whatcom Hospice which is the Transitional Care Model Naylor Model
and the Care Transitions Coleman Model. The model I have chosen to use is the Coleman
model because it addresses several aspects of hospice care used in current practice. The Coleman
model is a four pillar framework of interventions: personal health record, follow up appointments
with a primary health care provider and/or specialist, red flags, and medication self-management
(Lamb & American Nurses Association, 2014, p. 192).
The goals of Whatcom Hospice that reflect the Coleman model are to reduce hospital
readmission rates, allow patients to be actively involved in their plan of care, provide patient
education for understanding of red flags and taking appropriate action as necessary. For
hospice patients who reside in their home, education is provided regarding medication selfmanagement, which allows patients to do more for themselves. Once patients are placed on
hospice, they are accepting comfort care as their main source of treatment and are less likely to
be admitted to a hospital. The four pillars of Colemans Model are aligned with very similar
elements of the Whatcom Hospice program. Currently Whatcom Hospice uses guidelines and
criteria that have been set forth by CMS.
Literature Review
In reviewing the literature about Colemans Care Transition Model using the CINAHL
database, it became apparent that this model was developed and implemented to combat costly
hospital readmission rates (DeCoster, Ehlman, & Conners, 2013). The Congressional Budget
Office, 2010 reports that the United States health care costs are increasing and are a burden to the

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Federal budget and Medicare expenditures are expected to increase by 79% between the years
2010-2020 (DeCoster, et al., 2013). Decoster, et al. (2013) believes that there are multiple
reasons for hospital readmissions such as, inadequate discharge planning, insufficient follow-up
among health care providers after a patient has been discharged, and lack of support for family
and caregivers. Kelly and Starr (2013) believe that patient readmissions within 30 days of being
discharged are considered preventable and avoidable when appropriate measures are in place.
Colemans model addresses care transitions and describes it as the time when patients transition
from one healthcare setting to home, nursing facilities, and long-term care facilities (Decoster, et
al., 2013).
Colemans model improves communication between health care disciplines at the time of
the transition of care of the patient. The individual who acts as a member of the transitions team
can be a nurse, or other member of the health care team. Whatcom hospice receives several
hospital based referrals and the MSW acts as the first member of the transitions team. The MSW
meets with the patient and family to provide them with information about the hospice program.
The MSW coordinates care working with other members of the interdisciplinary health care team
and begins the process of discharge, hospice admission, as well as ordering them necessary
medical equipment. Once the MSW completes this process, the care of the patient is then
transferred to the hospice care team, including an RN who is the case manager.
Medicare describes the hospice model as the RN being the case manager, coordinating
the care of the patient and family putting them at the center of care delivery. The RN meets with
the patient on a regular basis, providing support and education to the patient and their family
concerning medication management and comfort. According to Kelly and Starr (2013)
Colemans model improves quality of care, educates and empowers patients.

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Care Map

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Synthesis of Care Map

The above care map includes a detailed analysis of a single patient and their family
member currently in the Whatcom Hospice program. The center has the patient and their family
member with comfort care around them, as this is Whatcom hospices philosophy of the
patient/family unit being at the center of comfort care. This patient and family member are
described in this case study.
This patient is a 71 year old female and the family member is her 50 year old daughter.
Her underlying chronic medical history includes chronic obstructive pulmonary disease (COPD),
asthma, hypertension (HTN), osteoporosis, congestive heart failure, and depression. This patient
was taken by ambulance from her home and transported to the emergency department (ED) at St.
Josephs hospital due to difficulty breathing. Her son who lived at home with her at the time
made the call to 911. Upon arrival to the ED, she was examined by the attending physician who
diagnosed her with acute respiratory failure and pulmonary HTN and she was admitted to the
hospital for five days.
Her prognosis was deemed poor by the physician as evidenced by her advanced age and
medical history related to multiple diagnoses and code for do not resuscitate, comfort measures
only. The physician mentioned hospice care to them and after a deep discussion concerning the
patients wishes and outlook with her family member, her daughter who was also present in the
ED, the patient decided to learn more about it. From there, the attending physician who treated
her in the ED placed a hospice referral in the electronic health record, which initiated a visit from
the hospice MSW to discuss comfort care and the hospice program.

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The MSW from hospice came to visit her in the hospital and provided her with
information about the program. The patient was initially reluctant in joining the hospice program
because she thought she wouldnt be able to return home or have her pet dog with her any more.
However she became grateful after learning that she would be able to stay at home with her dog,
while receiving comfort care through hospice. Another shared concern was that her son who
lives with her has a history of drug abuse so her medications wouldnt be safe. The MSW was
concerned for the patients safety as well as possible drug diversion if the son stayed in the home.
The MSW let the patient know that they would have her sign a contract stating that she was
liable for medications and diversion risk could be alleviated by using a lock box for her
medications once she arrived home. The patient indicated that she understood and had her son
move out of her house. She was concerned about being alone in her home, however she didnt
feel it was necessary to have HHAs for activities of daily living (ADL) so she discussed it with
her daughter, who agreed to move in with her and assist her with ADLs.
After these concerns diminished, the MSW worked with her to sign consent forms for
hospice care and discussed enrollment as it relates to her Medicare insurance and how to
interface with her physician. The discharging physician at the hospital signed the comfort order
set provided by hospice which allows for hospice interventions to begin. Although her daughter
was present, this patient is able to make her own decisions at this time, although a power of
attorney is in discussion. She was determined eligible for hospice care using CMS guidelines
meeting them with a diagnosis of COPD and pulmonary HTN.
The MSW made arrangements for durable medical equipment (DME) furbished through
Bellevue Healthcare, to be brought to her home before she was discharged from the hospital. Her
DME includes: a bedside commode, hospital bed, over-bed table, an oxygen concentrator and

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portable oxygen tanks as well as a walker and wheelchair. The MSW also discussed meals on
wheels with her but she is already receiving these services, nothing needed to change. The MSW
also discussed respite care services offered in the event of her needing it.
A day prior to discharge, the medication list was updated at the hospital and had new
prescriptions to be filled so the MSW faxed the new orders to the patients appointed RN case
manager. The RN case manager then faxed these medication orders to Hoaglands pharmacy and
delivered them to the patient the following afternoon during the first home visit. The RN case
manager performed a detailed nursing assessment and set up a plan of care working with this
patient to understand her goals. The RN case manager also discussed in detail, the new
medications as well as self-management regarding medication administration as well as pain
management. Symptom management related to COPD and pulmonary HTN was also discussed
as well as oxygen use and safety measures. The RN case manager provided the patient with
information about her role in care as well as answering questions and addressing concerns that
the patient had. The patient and her daughter discussed their goals of staying in her home and
only receiving comfort measures and the RN case manager shared how her goals would be
supported and met by the hospice care team.
The RN case manager took her time with the patient and let her know that a HHA would
be coming the following morning to assist her with a shower as well as a chaplain that would be
contacting her soon; however the patient declined chaplain service. Other services that were
offered included volunteer services in the home as well as massages, but the patient declined
these as well. The RN case manager contacted the chaplain later via fax stating that this patient
had declined as well as the others that were refused. The next day the HHA came and set up
twice a week visits to provide bathing assistance, as requested by this patient.

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The MSW made their first home visit at the end of the first week and let the patient know
more about bereavement services offered (Medicare requirement). The patient and her daughter
were informed that these services assist in understanding the dying process and help prepare for
death. The MSW also let them know that these services are extended for 13 months after death,
and offer helpful support to family. The MSW also provided them information about funeral
homes and help with end of life planning needs.
Care Plan
Smart Goal: Patient would like to remain safely and comfortably at home for end of life care.
She accepts hospice team members as supportive presence in her life as well as her daughter
Tammi who currently lives in her home for 24/7 caregiving support. She and her daughter have
been supported by hospice staff in regard to patient's decline. She does not want to return to the
ED or the hospital.
Problem: High fall risk
Goal: Patient experiences no falls
Intervention: Patient understands and uses walker when ambulating, and has a bed alarm;
daughter is available to assist her mother, the patient, during ambulation as well. As a safety
measure, a HHA comes to the patients home to assist with bathing twice a week.
Problem: Alteration in respiratory status
Goal: Breathing comfortably without effort as evidenced by patient denial of pain, shortness of
breath or use of accessory muscles and/or respiratory rate <22.

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Interventions: oxygen 10L/mask; Fentanyl CADD and titrate per comfort; nebulizers as
ordered; head of bed in up position to comfort.
Problem: Constipation related to narcotic use.
Goal: Has a bowel movement a minimum of every three days.
Interventions: If patient does not have a BM in three days then administer Miralax per hospice
protocol.
This plan of care is truly a holistic approach as hospice addresses all aspects of patient
care to effectively meet their needs. This patient has since, passed away peacefully in the comfort
of their home with her daughter and dog present. In review of the charting as well as
interviewing her RN case manager, the patients end of life goals were met and her family is very
satisfied with the care provided by hospice.

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References

DeCoster, V., Ehlman, K., & Conners, C. (2013). Factors contributing to readmission of seniors
into acute care hospitals. Educational Gerontology, 39(12), 878-887.
doi:10.1080/03601277.2013.767615
Kelly, M. D., & Starr, T. (2013). Shaping service-academia partnerships to facilitate safe and
quality transitions in care. Nursing Economic$, 31(1), 6-12.
Lamb, G., & American Nurses, A. (2014). Care coordination: The game changer: how nursing is
revolutionizing quality care. Silver Spring, Md: American Nurses Association.

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Appendix

Executive Summary
Kendra Calonita, Michelle Carrillo, Kathleen Minor, Jodi Newcomer
Nursing 442: Interdisciplinary Care Coordination
Summer 2016
Western Washington University
BSN Nursing Program

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Introduction

The Care Coordination project was conducted by a team of WWU nurses in conjunction
with Whatcom Hospice and our PE site mentor, Jodi Newcomer. Whatcom Hospice, a program
of PeaceHealth St. Joseph Medical Center, provides life-affirming care for patients and families
with advanced illness or disease. Serving patients in their own homes, assisted living, nursing
homes or the new Hospice House, Whatcom Hospice helps with the medical, social, emotional
and spiritual concerns that often arise during the final months of life. The core topics that will be
covered in this report are: a description of our specific community/population, how we chose
who to develop a care map for and what we accomplished during this PE experience, key
findings, and recommendations for the next group of Western nursing students.
The purpose of the partnership for Care Coordination was to learn about the different care
coordination models that Whatcom Hospice uses to care for their patients, and about what
resources are available for patients and their families. Whatcom Hospice is a program within
PeaceHealth St. Joseph Medical Center. Whatcom Hospice provides care for patients who live in
the community, whether at their own homes, assisted living, or in nursing homes and they also
recently built a Hospice House with 12 beds, for patients who are unable to be cared for within
the home. In order for patients to be eligible for the Whatcom Hospice program they must have a
6 month or less prognosis, present with metastatic disease and are done pursuing aggressive
treatment, or have advancing disease despite treatment.
Problem Description
Each member in our group was able to choose a different patient, however we were able
to work together as a group to come up with one care map because many hospice patients are
referred to hospice care but the hospice care team does not make many referrals for their patients
because the goal is to keep the patient comfortable during the last few weeks of life, once
aggressive treatment has stopped. Many of the resources used by patients and their families are
within the hospice care team. The hospice care team consists of admission nurses, nurse case
managers, field nurses, chaplains and volunteers.
Process/Methods
Our group was able to work with our PE site mentor, Jodi, to identify two different care
coordination models that are being used at Whatcom Hospice. After researching and reading
about the Transitional Care Model (TCM) and the Care Transitions Model (CTI) as a group we
decided that there are many aspects of both models that are integrated into the Whatcom Hospice
program.

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Key Findings/Results
The strengths of the Whatcom Hospice program that were identified throughout our
practice experience was their engagement with care coordination. They truly have a seamless
care coordination process that touches on all aspects of patient care. A positive implication of this
practice experience is that hospice care has so many care coordination activities and uses an
interdisciplinary team approach which makes it a very fulfilling learning experience. A negative
implication of this practice experience was that they use their own care model that has been set
forth by CMS, which made it more difficult to identify one type of care model.
Recommendations

Experience the different aspects of hospice care; follow a nurse working at the Hospice
House, a nurse case manager, an admissions nurse

Attend a visit with a medical social worker for patient referral in the hospital setting

Western faculty: flexibility with care models in the first section of the paper as some sites
may reflect more than one
Conclusion

In chapter eight of our assigned reading, Lamb and American Nurses Association, (2014)
describe care coordination as improving quality outcomes in regards to safety, medications and
self-care (p. 134). This is in-line with our individualized care plans that we have created for
hospice patients. One of the goals of hospice care is to educate patients about medication selfmanagement and is a measure of safety and self-care as well; the hospice program treats the
patient and family as a unit, as they are the center of care and all aspects of care coordination
involve them.