KEY FEATURES | GOALS | PLAN |
General |
- Presence of terminal diagnosis with discomfort/pain coupled with patient/family in need of more information and slower transitional process
- The Palliative Care Pathway can either stand alone or run concurrently with treatment of other co-morbid conditions, i.e.: post surgical care and wound care
| - Patient/family demonstrate understanding of disease progression and treatment effects
- Patient/family demonstrate understanding of end-of-life decisions, issues and options
- Patient maximize pain control/symptom management
- Maximize psychosocial support within home health model
- Maximize ADLs within patient’s ability/choice
| - Smooth and seamless transition into hospice if selected
- SN to provide pain and symptom management, instruction and support
- SN to order/supply any necessary DME and medical supplies needed for optimum comfort of patient.
- MSW to review 5 Wishes and Hard Choices with patient/ family
- Hospice trained CNA to transition with patient if level of care changes.
- Board Certified Hospice and Palliative Care physician available for visits or consultation
|
End Stage Renal Disease |
- Patient/family facing end-of-life issues and decisions due to terminal illness
- CC of 15mL/min
| - Patient/family demonstrate understanding of disease process
- Patient/family demonstrate understanding of complications possible from discontinuation of dialysis
- Patient/family demonstrate understanding of end-of-life options
- Pain/discomfort controlled within acceptable level
- Smooth, comfortable and welcome transition into hospice if selected
| - SN to teach and access medication regime, skin care and diet
- SN to obtain labs
- MSW to review 5 Wishes booklet with patient/family
- MSW to review Hard Choices booklet with patient/family
- MSW to discuss end-of-life options with patient/family
- Board Certified Hospice and Palliative care physician available for visits or consultations
- CNA if needed
|
Stage IV Cancer |
- Patient/family facing end-of-life decisions/issues due to various types of Stage IV Cancer
| - Patient/family demonstrate understanding of disease progression
- Patient/family demonstrate understanding of end-of-life decisions/issues
- Patient/family demonstrate understanding of end-of-life options
- Patients maximize pain control/symptom management
- Maximize psycho/social support within home health model
- Maximize ADLs within patient's ability/choice
- Patient/family demonstrate understanding of treatment effects
- Smooth, comfortable and welcome transition into hospice if selected
| - SN to obtain labs
- SN to teach diet
- SN to teach meds
- SN to assess side-effects of treatment and communicate with MD
- MSW to address self-image issues of patient
- MSW to review 5 Wishes booklet with patient/family
- MSW to review Hard Choices booklet with patient/family
- Board Certified Hospice and Palliative care physician available for visits or consultations
- CNA if needed
- PT to assess need for assistive devices if needed
|
End Stage CHF (Non-Surgical) |
- Patient/family facing end-of-life decisions/issues due to terminal illness
- Patient is non-surgical candidate with Ejection Fraction below 20%
| - Patient/family demonstrate understanding of disease process
- Patient/family demonstrate understanding of end-of-life issues/decisions
- Patient/family demonstrate understanding of end-of-life options
- Pain/discomfort adequately controlled
- Maximize psycho/social support within the home health model
- Maximize ADLs within patient's ability/choice
- Smooth,comfortable and welcome transition into hospice if selected
| - SN to obtain labs, weights
- SN to educate patient/family on med regime
- SN to educate patient/family on exercises, diet
- PT to assess need for assistive devices
- MSW to review 5 Wishes booklet with patient/family
- MSW to review Hard Choices booklet with patient/family
- MSW to review end-of-life options with patient/family
- Board Certified Hospice and Palliative care physician available for visits or consultations
- CNA if needed
|
Low Vision Support Program Guidelines |
- Decreased safety and independence related to decreased visual acuity.
- Visual acuity levels: 20/70 to 20/1,000
- We can help those who have:
- Diabetic Retinopathy
- Macular Degeneration
- Retinitis Pigmentosa
- Retinal Detachment
- Cataracts
- Glaucoma
- Decreased Visual Acuity - Legally Blind - Total Blindness
| - Patient demonstrates maximum ADL in an environment conducive to patient independence and efficiency
| - SN to perform admit and assess patient needs.
- OT to evaluate and modify home environment relative to patient’s ADL and safety.
- OT to provide appropriate training with devices.
|
Total Hip Replacement Guidelines |
- Decreased ability to ambulat post-op
- Decreased safety with gait post op
- Decreased strength post-op
- Presence of pain post-op
- Risk of DVT/PE post-op
| - Effectively manage anit-coagulant therapy.
- Patient demonstrates adequate mobility, ROM and ADL for optimal functionality.
| - Pre-op consultation if ordered.
- PT/OT to instruct in use of assistive devices.
- PT to perform and teach strengthening exercises/ ROM and home safety.
- PT to instruct with applicable hip precautions.
- SN to monitor medication regimen.
- SN to monitor effectiveness of pain medication.
- SN to administer/teach/ monitor coagulant therapy.
- SN/PT to assess wound status and remove staples.
- CNA and MSW if needed.
|
Total Knee Replacement Guidelines |
- Decreased ability to ambulate post-op.
- Compromised home safety.
- Decreased strength post-op.
- Presence of pain/post-op
- Risk of DVT/PE/post-op
| - Effectively manage anti-coagulant therapy.
- Patient demonstrates adequate mobility, ROM and ADL for optimal functionality in home environment.
| - Pre-op counsultation if ordered.
- PT/OT instruct in use of assistive devices.
- SN to monitor medication regimen.
- SN to monitor effectiveness of pain medication.
- SN to administer/teach/ monitor coagulant therapy.
- SN/PT to assess wound and remove staples.
- PT to perform and teach strengthening exercises/ ROM and home safety modifications.
- CNA and MSW if needed.
- OT to address ADLs when applicable.
|
Limb Loss Program Guidelines |
- Decreased safety and independence related to amputation
- Requires one of the following conditions:
- Single amputation
- Multiple amputations
- Pre-amputation training
| - Patient demonstrates high level of knowledge of the following:
- Wound care
- Shrinker training
- Sock management
- Limb hygiene
- Liner (equipment) hygiene
- Reduction of edema
- Contracture prevention
- Residual desensitization
- Proper prosthesis training and usage - Patient demonstrates maximum ADL in an environment conducive to patient’s independence and efficiency.
- Training all family members/caregivers in ADL training
| - SN to assess needs in conjunction with physician recommendations
- Communication with therapy and prosthetic specialists during rehab
- PT/OT to evaluate and direct improvements of home environment relative to patient’s ADL
- PT/OT to provide appropriate training in strength, stabilizing and range of motion geared towards independent/
- assisted ambulation
- MSW to evaluate psychological needs of the patient, family and caregivers
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Palliative Care 
