Kansas City Hospice Home Visits/Long Term Care- 2 blocks

Description:
The fellow will have a 12-month longitudinal opportunity with Kansas City Hospice & Palliative Care to visit patients in their homes and at long-term care facilities, with a concentrated frequency of visits during the two home/long-term care visit rotations.  The fellow will have opportunities to provide care in a consultative role to improve symptom management in conjunction with the home hospice IDT and collaborating with the patient’s primary community physician.  For patients choosing to have Kansas City Hospice physicians as the attending, the fellow will be able to take a primary role providing medical care.  The fellow will be supervised and assisted by members of the IDT on most home and long term care visits. 

During these blocks the fellow will work primarily with Dr. Harris.  Feedback and discussion of clinical issues will happen after the visit as they travel to the next visit.  As the fellow becomes more skilled in home visits, she will make visits independently of Dr. Harris and report back at the end of the day or during the visit, depending on the immediacy of any assistance. 

The fellow will be expected to make 8-15 new and follow-up visits per week while on home/long-term care visit rotation and 1-3 follow-up visits per month while on other rotations.  The home visit experience is one of the anchors to ensure patient care continuity across clinical sites.

Fellow Responsibilities

The fellow will work with the home teams of Kansas City Hospice & Palliative Care during home visit/long-term care rotations.  This Interdisciplinary team is comprised of a team manager, social workers, a chaplain, nurses (RN and LPN), care partners, and medical records.  Additional members of the IDT include music therapy, art therapy, child-teen specialists, bereavement counselors, and lymphedema specialists as needed for a given clinical situation.

Throughout the year and especially on the home visit/long-term care rotations, the fellow will follow patients from home teams in a consultative or attending role with support from the IDT members.  Many home visits are made concurrently with another member from the IDT allowing for good communication of the care plan and opportunity for teaching of the fellow from IDT members who have years of hospice experience.

The fellow will act as the medical director for a long-term care hospice team for Kansas City Hospice & Palliative Care.  The IDT will be comprised of a team manager, social workers, a chaplain, nurses (RN and LPN), care partners, and medical records.  The fellow will attend this two hour IDT weekly throughout the fellowship and provide medical direction and advice for appropriate hospice care plans for long-term care patients.  The fellow will communicate with the patient’s primary attending if a major change in medical orders is indicated.

The fellow will also communicate with the long-term care facility staff, including the patient’s primary physician and the director of nursing as necessary to ensure excellent clinical care.