Signs and Symptoms of Advanced Disease...
At Centric Health, we support a patient's wishes at the end-of-life, including the desire to stay in the place they call home. If a patient shows several symptoms below, your patient could be eligible for symptom management and medications to help control pain, for supplies and equipment to provide comfort, and for emotional support for the patient and their family.
WHAT TO LOOK OUT FOR:
- Progressive decline despite treatment
- Repeat hospitalizations / ED visits for same disease process in <90 days
- Unable to provide any self-care, unusual change in mobility or cognition
- Increase in fatigue; spending more of the day in chair / bed
- Increase in falls or unusual change in mobility
- Shortness of breath, even while resting
- Uncontrolled pain
- Stage 3 or 4 wounds
- Hospitalizations/treatments for recurring infections, fractures, dehydration, pneumonia
- Refusing / unable to eat or drink, unusual change in weight
- Numerous medication changes to help manage pain or symptoms
- Contacting their physician or healthcare professionals more frequently
Preventing Hospital Readmissions
Unnecessary hospital readmissions can present quite a challenge to the healthcare community.
- Nearly one in every five Medicare patients discharged from the hospital is readmitted within 30 days.
- Across all insured patients, the preventable readmission rate is 11%; for Medicare patients the rate is 13.3%.
- 836,000, or 12% of more than 7 million 30-day hospital readmissions that occur each year are preventable.
- Preventable hospital readmissions cost the US healthcare system an estimated $25 billion annually.
If these statistics are astounding to you, know that they are astounding to us too. These numbers affect all of us. In addition to the statistics, consider that the preventable readmission rates are highest among patients with conditions such as heart failure and COPD, end-stage diagnoses we see frequently in hospice patients under our care. We can help.
Challenges
- Symptoms/exacerbations with heart failure and COPD aren't typically predictable
- Patients & families inadequately informed about post-discharge care
- Changes in condition may be acute and unexpected
- Patients & families experience fear and anxiety
- Patients suffer from exacerbation in pain and/or symptoms
- Communication an coordination or care with post-acute providers can be a challenge
- Interoperability between multiple providers
- Challenges presented by COVID-19 pandemic
Centric Solutions
- Phone answered by a person, then in-person or Telehealth visits, as needed, for faster triage
- Proprietary Patient and family Handbook, for ongoing education and reference
- 24/7 availability to address changes and provide medication management
- Team of professionals to address patient/family fears, loneliness, stress, depression, anxiety, etc.
- HtoHH Speed to Care process, for prompt, smooth transition to our care
- Provider Link and Facility Link, our EMR portal solutions, give instant access to patient information
- Access to networking platforms that connect participating providers, sharing Admission, Discharge, and Transfer data
- Admissions and cisites, whether patient is positive or negative for COVID-19, and in-person or via Telehealth; multidisciplinary effort to keep patients & families together, in their home
Your Centric Hospice Care Team
Physicians
Medical Directors, in conjunction with the patient's primary care physician and the hospice care team, create a care plan that manages pain and controls symptoms associated with the patient's terminal illness or disease.
Nurses
Skilled, experienced Registered Nurses (RNs) and Licensed Vocational Nurses (LVNs) provide hands-on medical care, while assessing the needs and managing the pain and symptoms of patients. Nurses also provide support for family members and help educate them on how to assist in caring for their loved ones.
Social Workers
Social Workers help patients and family members deal with a range of issues, such as communication, conflict resolution, or other stressful situations. They can also coordinate available community resources and assist with matters that are not medical related, including finances, planning, insurance benefits and other end-of-life concerns.
Specialized Therapists
Specialized therapists are available as needed to assist patients through particular challenges. These include music and pet therapy at some locations.
Chaplains/Spiritual Care Coordinators
Chaplains, or Spiritual Care Coordinators, provide spiritual support to patients and their loved ones, guiding them through tough end-of-life questions and decisions, while helping to restore family relationships. They can involve personal clergy from any denomination or other individuals with experience in spiritual support.
Hospice Aides
Hospice Aides - Certified Nursing
Assistants (CNAs or Home Health
Aides (HHAs) - assists with a patient's
personal care, such as dressing and
bathing, as well as other activities of daily
living. They also provide companionship and emotional support for patients and families.
Bereavement Coordinators
Bereavement Coordinators help patients and loved ones prepare for the different phases and situations involved in the end-of-life process. They continue providing bereavement support and grief counseling to the families for up to 13 months.
Volunteers
Trained volunteers provide companionship and support while visiting periodically and spending quality time with patients. They assist with simple caregiving responsibilities and may help with simple household chores if needed.