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• Overview and definition of palliative care
• Current state assessment
• Building a maturation model
• Key drivers of success
• Outcome measures/metrics
• Implementation considerations
• Q&A
Agenda
Overview & Definition of Palliative Care
Understanding the Continuum of Illness
Continuum of illness
Diagnosis
Saint Luke’s Health System Palliative Care Vision:
Saint Luke’s Palliative Care Service will provide care to
patients with serious, chronic, life-threatening illnesses
and support their families and caregivers. The goal is to
improve quality of life, reduce suffering, and provide care driven by the patient’s wishes. Palliative care is a supportive service provided by a multidisciplinary teamthroughout the progression of a patient’s disease.
Palliative Care Vision
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Understanding first-hand the impact palliative care can have on our patients’ lives…
Patient Stories
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• Clearly defined program scope/vision
• Interdisciplinary team with clear roles and responsibilities
• Clinical practice guidelines for identification of patients and utilization of services
• Organizational staff orientation and education about program services
• Clear criteria and protocols for physical and psychological symptom management
• Clearly defined processes to resolve ethical conflicts
• Procedures regarding discharge or transfer
• Patient-centric educational information
• Program-specific performance improvement processes
• Patient and family satisfaction data tracked
Attributes of an Effective Palliative Care Program
Source: NQF Preferred Practices & Requirements for Joint Commission Advanced Certification in Palliative Care 7
Building A Strong Core Palliative Care Team
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Palliative MD’s & APP
Dedicated Palliative RN & Social Worker
Chaplain, Pharmacist, Dietician, Speech Therapist
Support across the health system
Core Palliative Care Team Roles & Responsibilities
• Initial inpatient consults
• Inpatient follow-up
• Answers questions about symptoms and prognosis
Palliative Care MD
• Inpatient follow-up
• Symptom management
• Coordination with PCP, specialists, and rest of Palliative team
• Guide family through complex situations of hospitalization & care at home
APP
• Additional education (symptoms, medication side effects, etc.)
• Answering patient/family questions regarding care plan; ensure understanding of care plan and options by patient and family
RN
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Ancillary Palliative Care Team Roles & Responsibilities
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Social Worker
Chaplain
Pharmacy
Nutrition & Speech Therapy
• Assisting in coping with “losses” as condition progresses – of health, of roles and responsibilities, etc.• Advocate for patient access (i.etransportation issues)
• Lead case conferences – with family, patient, necessary team members• Advance care planning documents and decisions – Advance Directives, DNR, etc.
• Initial inclusion in the development of palliative care guidelines and patient pathways• Weighs pros & cons of prescription options with patient and MD
• Education on…•Using one drug for several symptoms•Drug interactions•Pain medications and side effects•Multiple routes of administration
• Provide spiritual support and help to address questions (i.e. Why me?)
• Provide cultural awareness to the care team
• Nutrition can help with Initial inclusion in the development of palliative care guidelines and patient pathways
• Speech Therapy helps with PEG tube placement and swallow studies
Palliative Service Proposed Sites of Care
Community
Based CareAcute Care Post-Acute Care
Palliative Hospital
ServicesHome Palliative
Care
Transfers to
Hospice
OP services
ePalliative Care
PCP offices
LTACs / SNFs
Community
Partnerships
It is imperative that SLHS shores up Palliative Care Services in the Acute Care setting prior to launching services at additional sites of care.
Critical Care
Palliative ICU
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Current State / Assessment
Why Palliative Care?
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Building a Palliative Care Program is an imperative to helping SLHS achieve its Vision to become a patient-centered, high-value system of care.
Mission Critical
As a not-for-profit, faith based health system, this presents an opportunity to provide well-coordinated palliative care services that don’t exist in the communities we serve.
Patient Centric
Put the patient’s goals first and choose interventions that align with those goals.
Increase patient and family satisfaction.
Business Impact
Decrease inpatient costs by reducing unwanted or unnecessary interventions.
A care plan will also reduce readmissions.
Decrease use of the emergency department.
Increase use and length of stay in hospice which is less costly.
• “Palliative Care is everyone’s responsibility and no one’s responsibility.” –Cardiologist
• “To have a healthy bottom line, you have to have an effective Palliative Care Program.” – Emergency Medicine Physician
• “We must identify Palliative Care as more than just a strictly inpatient service.” –Administrator
• “The underpinning of care should be ‘therapeutic listening’, and the scarce resource will always be time to listen.” – Spiritual Wellness
• “Providers consider Palliative Care as hospice-lite.” – Primary Care Physician
• “Physicians often say, ‘My goal today is to make you…’. The conversation has to shift to, ‘What is your goal for today?’” – Pulmonologist
Current State of Palliative CareStakeholder Interviews
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• Palliative care currently seems more closely aligned with end of life rather than symptom management.
• Palliative physician workforce is severely understaffed.
• In the current state, palliative care is engaged either too late, or not at all. Therefore, a culture to engage palliative care earlier and focus on the patient’s goals is absent.
• No scripting to help physicians start a conversation with their patients to engage palliative care services.
Other Common Themes from Interviews
15
Peer Comparison for Palliative Care
SLH Compared to UHC Database
The most recent quarter trend
indicates that SLH observed an
uptick to 8.6%. This is still
significantly lower than the best
decile of Academic Medical
Centers.
UHC comparative data indicates that SLH is failing to provide inpatient palliative care services when appropriate.
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Building A Maturation Model
Palliative Care
Program
Access
Education
Advanced Care Planning
Culture Change
Palliative Care Program ComponentsThere are several key components which are necessary to build a mature Palliative Care Program. These include: access, education, culture change, and advanced care planning.
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Level 1 Level 2 Level 3 Level 4
Access
Team:• MD, APP, Social Worker, RN, Pharmacy, Chaplain, Nutrition, and Speech
Sites of Care:• Target IP ICUs in metro
Patient Population:• Serious, life-threatening illness• High LACE score• <6mo. Prognosis
Team:• Recruit Medical Director
Sites of Care:• Expand focus to OP clinics and all IP
Team:• Expand team as needed
Sites of Care:• E-Palliative• Home-based care
Patient Population:• Serious, life-limiting illness• Uncontrolled symptoms of chronic disease• <12mo. prognosis
Team:• Integrate alternative medicine services
Sites of Care:• All sites of care
Patient Population:• Uncontrolled symptoms of chronic disease• No prognosis limitations
Education
• Internal education and communication• MD Peer to Peer education• RN “Train-the-Trainer” approach
• Education retreat for key stakeholders• Patient/family education materials • Ongoing internal communication
• Ongoing internal marketing• Patient/family testimonials
• Explore Palliative Care fellowship possibilities
AdvanceCare
Planning
• Require employees to fill out advanced directive
• Support OP clinics and employer sites with advanced care planning services
Culture Change
Conversational scripting to help primary palliative care delivery
External marketing & communications
•Partnership opportunities with post-acute facilities
•Joint Commission Certification•Circle of Life award
ICU Palliative Screening Trigger Tool
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Guide to LACE Score Tool
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• Help improve communication and conflict over goals of care and end-of-life care
• Reduce psychological distress among family members
• Reduce length of stay and the use of low-value care
• Help manage complex physical or psychological symptoms
• Provide psychosocial or spiritual support
Utilization of palliative services is dependent upon strong interdisciplinary communication amongst providers and shared understanding of services
Benefits of Palliative Care related to Critical Care
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Key Drivers of Success
• Medicare now covers advance care planning
• Education about differences between palliative care and hospice care
• Cultural shift towards understanding that a high quality death should be part of high quality care
• Legislation helping foster education and end of life care (i.e. TPOPP)
Key Drivers to Help Promote Success
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Outcome Measures/Metrics
• Increase IP palliative consults - target range within UHC best quartile
• Decrease in ICU length of stay for populations with palliative consult
• Increased LOS on hospice following a palliative consult• Decrease use of the emergency department for key
diagnoses following initial palliative care consult• Decrease in patients readmitted after a palliative consult
(compare to UHC peers)• Estimated cost savings• Increase in number of palliative consults upon first
diagnosis for CHF, advanced breast, lung cancer• Increase in number of advanced directives in EMR• Patient satisfaction
Metrics to Understand Value & Impact
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Implementation
Level 1 Implementation 2016 Milestones
Develop screening,
identification, and
protocols in metro ICUs
Finalize Team
Composition
and Roles;
Recruit additional
team members
Providers credentialed at
all metro hospital locations
Develop and
implement peer to
peer education
programs, patient
and family education,
and community
education programs
and materials.
Establish
Palliative ICU
Services at all
metro ICUs
Develop &
Track
Metrics for
pilot
evaluation
Review of pilot
program metrics
and assess for
adjustment of
scope; identification
of staffing needs as
program
progresses
Establish
Advanced
Care
Planning
Assistance
at all Metro
IP Facilities
Engage Cultural
Diversity and Ethics
Committees on
conversational
scripting for medical
professionals
Access
Education
Advanced Care Planning
Cultural Change
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Evaluation
Progress to Plan
• Define IP palliative consult process – build trigger tool within EMR
• Develop staffing/workforce requirements with clearly defined roles
• Standardize approach on how patients are informed about palliative care
• Billing opportunities – accurately capture activity on professional side
• Build relationships and foster interdisciplinary communication –nurses are key driver of growth
• Verbiage is important – “palliative” vs. “hospice”
• Culture and identifying the right champions is a huge component of successful adoption
• Leverage industry resources – CAPC, IHI “The Conversation Project”, AAHPM
Implementation Considerations
29
ABC World News with Diane Sawyer: TheConversationProject - YouTube
Caring Conversations
In the end…
“We have come to medicalize aging, frailty, and death, treating them as if they were just one more clinical problem to overcome. However, it is not only medicine that is needed in one’s declining years, but life---a life with meaning, a life as rich and full as possible under the circumstances.”
- Oliver Sacks
Q & A
