The questions are attached with all the material only use the material from what i post nothing else thank you You must include clear healthcare examples for each and every question to show that you

The questions are attached with all the material only use the material from what i post nothing else thank you You must include clear healthcare examples for each and every question to show that you
Instructions: Use works that have been assigned to the class to support your answers or you will not receive credit. Write in complete sentences; Do NOT simply list bullets Use proper APA citation and referencing. Points Considering the materials from Week 5 – Ethical Issues and Disparities in Hospice Care: Discuss what can be done to increase the equity of access to hospice care for marginalized and vulnerable populations? 25 Based on the case studies presented in, “Patient-Centered Care: Case Studies on End of Life,” answer the following questions based on the following cases (Case #1: Mr. J ; Case #2: Ms. L and Case #3: Mr. D: What are two lessons learned from each case regarding hospice care? What are two challenges faced presented in each case? What conclusions can be drawn from studying these cases? 25 Based on the articles, “Integration of Palliative Care into COVID-19 Pandemic Planning” and “Hospice and COVID-19.” Describe how Hospice Care facilities have confronted the challenges presented by the COVID-19 pandemic? 25 Chris, 37, is the sole caregiver for his mother, Michelle who is at home after she suffered a severe stroke. He is feeling overwhelmed by the physical, mental, emotional, and financial stresses of caring for her. Provide specific examples and explain in detail how a hospice interdisciplinary team can help with each of the challenges presented in this scenario. 25 Instructions for Final Exam
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Education, Care Coordination Essential to Expanding Pediatric Palliative Care By Holly Vossel March 4, 2022 Pediatric patients are among the most underserved seriously ill population in hospice and palliative care. Hospices have worked to expand their scope of pediatric services, with a focus on increasing access to palliative care and opening up referral streams. Compared to adults on hospice, children represent a smaller but crucial group of patients, according to Joe Rotella, M.D., chief medical officer of the American Academy of Hospice and Palliative Medicine (AAHPM). “Children are a very important population that is underserved by palliative care,” Rotella told Hospice News. “Any palliative care providers that are treating just adults ought to be looking at the unmet needs of pediatric palliative care in their community and thinking about a way to provide that. Pediatric palliative care looks different than in adults but every bit as important, if not more so.” The large bulk of hospice and palliative care patient populations are older adults. Nearly 63% of Medicare decedents who received hospice care in 2019 were 85 and older, according to a Medicare Payment Advisory Commission (MedPAC) report. This compared to less than a third (29.4%) under the age of 65. But the incidence of serious and chronic illness is not limited to seniors. Each year an estimated 500,000 children present with a serious illness in the United States, with many becoming hospice-eligible within a year, according to 2018 research published in the Journal of Pain and Symptom Management. These patients account for roughly 45,000 deaths nationwide annually, a 2019 study found. Underutilization of pediatric hospice and palliative care occurs for myriad reasons, including the reality that the needs of terminally ill children are distinct from those of adults. Providers need specialist knowledge regarding medication dosing, specialized equipment and assistance with family dynamics and support. “Pediatric palliative care is highly complicated and complex,” said Harold Siden, M.D., medical director at Canada-based Vancouver Canuck Place Children’s Hospice. “One issue is the nature of the conditions. There is often a long period of chronic care involved with children.” As is often true for palliative care in general, families of seriously ill children are frequently unaware of the nature of those services. Many among the public — and some clinicians — conflate those services with hospice, and families often fear losing their other health care options. Few understand that laws and payers generally allow children to receive concurrent curative care. The availability of concurrent care presents both challenges and opportunities for providers. On one hand, it enables them to bring more pediatric patients under their wings. On the other hand, it can complicate back office processes like billing.  Ensuring regulatory compliance when providing concurrent care can also become complex, requiring consistent and effective communication with state agencies and care coordination with the patient’s other health care providers. The large majority of those providers are primary care or or subspecialty clinicians, according to American Academy of Pediatrics (AAP) research.  Seriously ill pediatric patients are a relatively small population, but tend to generate a somewhat disproportionate amount of health care costs. These patients represent less than 10% of the U.S. population but account for at least 50% of hospital resources for youth patients, according to AAP research. Palliative care’s track record on reducing hospitalizations is an important component of its value proposition when it comes to reducing the spend. But that care does not exist in a vacuum. Developing and expanding pediatric palliative care programs depends on the quality of referral relationships with these and other clinicians, Siden told Hospice News. “Pediatric palliative care fills a small part of the overall referral pie,” said Siden. “Working alongside this treatment orientation in partnership is a key element of pediatric palliative care, rather than seeing it as an either/or proposition.” Because this level of coordination is essential, palliative care teams are constantly focused on facilitating and maintaining relationships with referring clinicians, according to Raya Elfadel Kheirbek, M.D., professor of medicine and chief of gerontology, geriatrics and palliative medicine at the University of Maryland School of Medicine.  “Consistently receiving appropriate referrals stimulates growth and keeps [these] programs thriving,” Kheirbek told Hospice News over an email. “Though the dynamics may vary from institution to institution, palliative care specialists share common obstacles when it comes to building these essential relationships. Most often, it begins with effectively showing how palliative care can support the efforts of clinicians as all parties work together to give seriously ill patients the best care possible.”
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Patient-Centered Care: Case Studies on End of Life Introduction People experiencing homelessness have diverse and complex health needs that can become increasingly difficult to manage when individuals are diagnosed with terminal or life-limiting conditions. As Dr. Pia Valvassori of Health Care Center for the Homeless in Orlando, Florida, explains, “We’re seeing people experiencing homelessness in their 50s and 60s with a number of chronic health conditions that have gone untreated for extended periods of time (such as Chronic Obstructive Pulmonary Disease, diabetes, infectious diseases, severe mental illness, etc.). We have a shortage of affordable housing units so we try to house those who are most vulnerable in permanent supportive housing. Some of the challenges our patients face include severe mental illness, competing priorities, and barriers and stigma associated with accessing care. It is well documented in the literature that the life expectancy of people who experience chronic homelessness is 12 years less than that of the general population.” Mortality rates amongst people experiencing homelessness are estimated to be three-to-four times greater than the general U.S. population1, and the number of older adults without homes is expected to increase to 95,000 by 2050.2 In order to respond to these types of complex situations, patient-centered care is a therapeutic approach that places the patient at the center of the treatment process. Patient- centered care involves focusing on the needs, values, and wishes of the patient when developing a health care plan. The process of providing patient-centered care can become even more complex when clients are facing the end of their lives. Patient-centered palliative care seeks to relieve suffering and improve the quality of life for individuals who are not likely to recover from their diseases, while also respecting their autonomy and their right to make their own decisions about their health care. The five case studies presented in this issue of Healing Hands will highlight issues and challenges that clinicians may confront while providing palliative care to patients experiencing homelessness. Case #1: Mr. J Case study Mr. J was a man in his mid-50s who was admitted to a recuperative care program in Portland, Oregon, after living outside for 15 years, mostly in a forest. He was admitted to the hospital with severe lung problems and then referred for recuperative care to a residential medical respite care program that provided short-term housing for people with acute medical needs. When first referred for care, Mr. J was difficult to engage and closed off. He had various beliefs not consistent with the care providers’ medical knowledge regarding the impact of any inhaled powder. As a result, he would not take any inhaled powders or anything with steroids in it, believing that they would harm him. Despite his care providers’ explanations that steroids are an essential part of effective management of lung problems, Mr. J did not want to take them. The care providers did what they could to arrange his treatment within those limitations, but his fixed beliefs about medications significantly limited therapeutic options. After Mr. J was referred to the medical respite care program, his case managers learned that he had been receiving a regular disability check but was spending most of the money paying for two storage units filled with furniture from the house that he had left 15 years earlier. At first, Mr. J did not feel he could give up that furniture, but after a month in respite care, he was reunited with a family member and began to pass on some of the stored items to her. Soon after, Mr. J requested of his own volition to be discharged from respite care. He was depressed and had begun speaking about his partner who had died in his arms 10 years prior and was buried in the woods where he had lived; he was heartbroken to think about her being alone in the woods and felt he needed to return to live near her burial place. Despite offers, Mr. J was not remotely interested in treatment for mental health conditions or therapy for care providers accurately assess their capacity? Mental health: What if a person has a mental health issue interfering with his decision-making process? What if depression is playing a significant role and may affect whether the patient makes choices that may lead to likely death? Patient’s beliefs: What should a care provider do when the patient’s beliefs conflict with medical evidence or the care provider’s experience? Patient’s goals: How can a care provider respond when a patient’s goals are not in his own best interest? lessons learned Work within patients’ frameworks. This is especially important with homeless care and people who are disaffected with the system. In this case, Dr. Rieke transferred all of Mr. J’s medications to non- powder form and managed to convince him to take steroids when he realized that he would be giving up oxygen. From a harm reduction standpoint, Dr. Rieke prescribed more than she typically would, realizing that Mr. J would probably not use the medications optimally but that the risk of long-term side effects from misuse were less than the risks of not taking them. The depression; instead, he insisted that all he wanted was to be discharged so he could return to the forest. Dr. Eowyn Rieke, Associate Medical Director of Primary Care at the Old Town Clinic of Central City Concern, explains of this case: “I knew he was discharging himself to likely death… It forced “Work within patients’ frameworks. This is especially important with homeless care and people who are disaffected with the system…” care team then discharged him, as he wished, and encouraged him to come back to respite care by going to the hospital and telling them that he wanted to return for care. Mr. J never returned to the hospital, and Dr. Rieke believes that Mr. J did not survive his return to the forest. me to question whether he had the capacity to make decisions, [given that he was making a decision] with the likely outcome of him dying… Prior to being discharged back to the woods, there was a moment when I wasn’t sure whether I was engaging in traditional medical care where the goal is to get better, or whether it was palliative care with the goal of feeling better, or maximizing function recognizing that he had a life-limiting illness. He was experiencing so much depression and cognitive problems that it was hard to identify whether he could honestly make a decision to forego his medication and the oxygen he needed.” Challenges Presented Capacity: At what point do people have the capacity to make their own decisions, and how can Have direct and specific conversations about the patient’s goals, particularly in cases that teeter on the edge of curative versus palliative care. As Dr. Rieke explains, “From a palliative care perspective, the questions would have been: How can I make you comfortable, recognizing that your time is limited? But I was still really focused on the getting better piece. In retrospect, I probably would have had a more direct conversation with him about exactly what his goals were, because then it would have been even more patient-directed. I could have said, ‘I’m worried you’ll die.’” Engage with patients as a team. Dr. Rieke believes that an important component of responding to Mr. J’s case was engaging a team of case managers and people to help him get to appointments and access care. “We didn’t think he was going to be willing to engage her pain. While Ms. L wanted to seek help for her addiction to substances, some of the traditional models were not appropriate given the magnitude of her physical issues. There were expectations that she would get into outpatient treatment but she did not follow through, primarily because it was difficult for her to tolerate being in groups for long periods. (Given the location of her cancer, she could not sit upright for long periods or on the bus for transportation.) Ultimately, Lawanda Williams, Director of Housing Services at Health Care for the Homeless in Baltimore, Maryland, and her team were able to provide Ms. L with transportation and cab vouchers so she could access the full course of radiation that doctors had recommended. Her pain was never well controlled, because her physician refused to prescribe her any pain medications, due to the magnitude of her substance use. The radiation center gave her at all,” said Dr. Rieke, “so it was especially important in his case to facilitate him in making decisions about his own care. We tried to be explicit about the power he had in the situation and emphasize that he was in charge of his own care.” Still, Dr. Rieke wishes that agencies had more capacity to interact with people on the far edges of engagement due to logistical and attitudinal “I have been able to see how managing withdrawal and managing substance abuse in the context of a palliative care treatment plan does not always exist for patients experiencing homelessness.” – Lawanda wiLLiams, director of Housing services, HeaLtH care for tHe HomeLess, BaLtimore, md Percocet while she was there but would not give her anything that could not be directly supervised. After treatment, they sent her home with prescriptions for Tylenol and instructions to return and follow up with pain management teams, which she was unable to do because of her difficulties with transportation and sitting. Ms. L completed radiation and is in a period of holding to assess effectiveness of the initial course barriers. “More outreach could help overcome these barriers,” she says, “and create more opportunities to have these crucial conversations.” Case #2: Ms. L Case study Ms. L is a 47-year-old African American woman who was diagnosed with vulvar cancer at the beginning of 2017. She is also HIV-positive. By the time Ms. L engaged in care, the cancer had proliferated quite quickly in the setting of a compromised immune system. Upon discovery of the Stage 4 cancer, doctors recommended a dose of radiation and chemotherapy. However, during the course of this episode Ms. L was struggling with substance use. During her hospitalization, she tested positive for a number of substances, including heroin and cocaine. As a result, care providers had many discussions about pain management and which pain medications could be given to her. She was not on methadone treatment maintenance at first, so she was self-medicating to address of radiation, but she still does not have a prescription for her significant pain and, as a result, continues to use substances to manage her pain. Ms. Williams observes, “I have been able to see how managing withdrawal and managing substance abuse in the context of a palliative care treatment plan does not always exist for patients experiencing homelessness. She does not fit very neatly into any mainstream treatment model.” Challenges Presented Harm reduction: How can care providers best advocate for a harm reduction approach while seeking to deliver palliative care services, including hospice care? Withdrawal: What role should withdrawal management play in the development of a palliative care plan? Pain management: What are the best pain management approaches for cases in which extreme pain is combined with active addiction? What is the dynamic between balancing a physician’s sense of risk management and concern about overdose with the client’s need for adequate pain control? Location: What treatment locations can be considered as options for people who need intensive care and palliative care? How do the options change when addiction is also involved? lessons learned Recognize the impact that addiction has on health care. Harm management principles can provide useful perspective on how to best assess the relationship between addiction, addiction treatment, and pain management. According to Ms. Williams, “there’s a need for really being able to balance treating addiction as a component of end-of-life care. How does one do that, and how can physicians achieve that as safely as possible?” Consider the client’s priorities and desired outcomes. In this case, doctors had at first proposed a radical surgery that would have involved taking off an entire side of her labia, but Ms. L had deep concerns regarding the aesthetic impact of such a surgery. The care plan changed to instead focus on a course of radiation, and Ms. L was relieved that the treatment would not involve disfigurement. Ms. Williams notes: “Initially I was pleasantly surprised to see how well her body responded to the treatment. There are still concerns about what might be going on inside, but aesthetically her result—which was really important to her actually, as it related to her relationship—she got the result there that she wanted.” Consider the client’s location. As Ms. Williams explains, care providers should develop “an appreciation for the client’s location—including where they are staying and whether they are homeless on the streets or in a housed environment that is not conducive to healing or recovery from substance abuse.” She notes that actual and potential locations are key for integrating substance abuse treatment, as well: “Often when people have a myriad of different issues, you want to refer out. In some ways, I feel like when individuals are facing end of life, those services should be collapsed in. When we’re doing palliative care, I can pull from these other areas. For example, having palliative care physicians and providers who are willing to do substance abuse treatment in tandem, or provide medications that will prevent withdrawal or manage withdrawal. How can the physician manage withdrawal symptoms in the context of end-of-life care?” Case #3: Mr. D Case study Mr. D was a man in his early 60s. After being unsheltered and uninsured for 5-to-6 years, with an underlying diagnosis of alcohol and substance use disorders, he developed liver disease. Dr. Pia Valvassori and her team at Health Care Center for the Homeless managed to help him secure housing, but due to issues with identification, Mr. D was unable to get immediate access to specialty care services. Three weeks after being placed in permanent supportive housing, a caseworker found him unconscious in his unit and took him to the emergency room, where it was discovered that his end-stage liver disease had progressed to the point where the only option was palliative care. However, care providers had no advance directive for the patient, nor documentation of his wishes for end-of-life care. After being placed in residential hospice care, Mr. D regained consciousness and was able to vocalize his wishes. He expressed that he wanted to be a “full code,” meaning he wanted hospital staff to intervene if his heart stopped beating or if he stopped breathing. In the end, he was readmitted to the hospital and his status rapidly deteriorated. The hospital and hospice care provider contacted his daughter, who lived out of state, and he died within 10 days. Challenges Presented Autonomy: Are conversations with patients about their wishes and goals being conducted as soon as possible? Beneficence: Are care providers assuming that they know the wishes and best interests of clients without consulting them directly? lessons learned Train staff on the usage and development of advance directives, and introduce documentation early in the process. At Health Care Center for the Homeless, staff are trained by hospice care providers on developing plans for end-of-life care with patients. Staff members now have Five Wishes documents ready to review with clients and scan into electronic health records. “For us,” explains Dr. Valvassori, Mr. D’s experience “was a lesson that… we are going to uncover all kinds of things once we’re able to engage patients, and we really need to put advance directives at the top of list of conversations to have. We can’t make assumptions, since we want people to be engaged in making their decisions on their own.” Try to access insurance as soon as possible. Mr. D had no health insurance, “sick as he was,” explains Dr. Valvassori, “and I feel like a lot of this could have gone differently. For example, if we could get him in to see a specialist, which we couldn’t because of insurance, we could have had a diagnosis and could have discussed these things.” It can take time to access services because of a wide variety of access challenges and technicalities, so if a patient is very sick, care providers cannot afford a delay in accessing any specialty care that is available. Acknowledge patients’ right to autonomy and self- determination. As Dr. Valvassori says, “I think probably one thing I learned is not to impose our own personal views on what we think a patient will want… We were surprised when in a lucid moment he verbalized ‘full code’… So we learned about having respect for the patient’s perspective, and not going in with your own preconceived notions.” . National Health Care for the Homeless Council HCH Clinicians’ Network P.O. Box 60427 Nashville, TN 37206-0427 www.nhchc.org Healing Hands received a 2013 APEX Award for Publication Excellence based on excellence in editorial content, graphic design & the ability to achieve overall communications excellence. © Mark Hines The HCH Clinicians’ Network is operated by the National Health Care for the Homeless Council. For membership information, call 615-226-2292.