Community, financial support help palliative care programs grow
Focus on frontline staff for extra support
[Editor's note: This is the first part of a two-part series about best practices in palliative care programs. This month we look at an overview of three palliative care programs that were awarded the Circle of Life Award: Celebrating Innovation in End-of-Life Care by the American Hospital Association and the use of research to develop best practice and establish benchmarks. Next month, we'll look at special programs to address challenging populations, including patients with chronic disease.]
Creating a palliative care program that follows a patient through all levels of care, regardless of health care facility, enabled Four Seasons, a hospice and palliative care agency in Flat Rock, NC, to grow from serving just 26% of the deaths in the community to serving 76% of deaths in the community in just a few years.
"Our board made a decision in 2002 to expand the palliative care program to reach more people beyond our hospice patients," says John Morris, MD, medical director of palliative care and vice president of clinical outreach for the agency. "Our medical system is fragmented," he says. "In most communities, palliative care is offered in the hospital; then, when the person leaves, the palliative care service stops."
Depending on the type of care to which the patient is discharged, palliative care might be available, but the patient and family have to remake decisions and examine options with another agency, he explains. "We start with the patient in the hospital and follow them through home health, nursing home, or hospice," Morris adds.
Four Seasons' palliative care team of two physicians, eight nurse practitioners and physician assistants, a registered nurse, a social worker, and a chaplain are able to practice in different settings as a result of agreements with agencies and facilities throughout the community, he explains. Physicians go through the credentialing process at hospitals and nursing homes so they can serve as consulting physicians, Morris says.
"We are also careful about which staff members are assigned to different types of facilities," he says. "Some people are comfortable in the hospital setting but not in the patient's home or in a nursing home."
Staff members who work in nursing homes are not only comfortable doing so, but they also have familiarized themselves with the special challenges of nursing homes, including the rules and regulations that govern them, so they can best serve patients, he says.
Palliative care programs are not required to follow Centers for Medicare & Medicaid Services' Conditions of Participation or seek accreditation on their own, but Morris believes it is important to follow guidelines and have protocols that use best practices. "We follow the National Quality Forum's guidelines, and we are constantly evaluating our service to see how we perform," he adds.
At Wishard Health Services in Indianapolis, the palliative care program is hospital-based, but it is designed to reach the most challenging population in the area. "We are a safety net hospital, and we serve people who are especially vulnerable," says Gregory Gramelspacher, MD, professor of medicine at Indiana University and director of Wishard Health Services Palliative Care Program. "To meet the needs of the poor and dying, we must provide services outside the walls of the hospital."
Wishard's palliative care team provides about 600 hospital consultations each year, but the care doesn't stop with the consultation. "We continue to provide care when the patients leave the hospital, whether or not they are hospice patients," says Gramelspacher. Although the team members will make home visits, many of the patients are homeless, he explains. Agreements with local nursing homes and hospices enable the staff to find a safe place for the patient.
Wishard's palliative care patient population is 60% African American, with a high Hispanic percentage and 40% with no insurance, says Gramelspacher. Although studies have shown that African Americans are less likely to choose hospice care1, the trust that develops between the palliative care provider and the patient enables the provider to suggest the best option for care, he says.
"We accept where they are in their decision-making process, and we don't force them to choose hospice if they don't want, but we've found that patients under our care are admitted to hospice earlier than other patients," Gramelspacher says.
There are financial challenges for palliative care programs, he admits. Although clinicians can bill for their services, many of the services provided by team members such as the social worker are not reimbursed, Gramelspacher explains. "Palliative care is underwritten by the hospital because the value of palliative care services is in the savings realized by the hospital," he says. "We are able to treat the patient in an appropriate setting and avoid unnecessary emergency room visits, intensive care stays, and hospital admissions."
Palliative care team created
At Oregon Health & Science University (OHSU) in Portland, a Palliative Medicine and Comfort Care team was created as part of a mission to better serve people in the small, rural hospitals in that state. "We provide staff education so that hospital personnel understand palliative care and the important role it plays in a patient's care," says Erik Fromme, MD, assistant professor of medicine in the Division of General Medicine and Geriatrics at OHSU and director of the OHSU Palliative Care Research Program. "When we first started the program we focused on patients and their families, but then we realized that staff members were often as distressed as family members and needed to be part of the palliative care process," he says.
In addition to educating staff members, Fromme's group also offers support services for hospital staff in the form of "debriefings" following a difficult case. "We may only get one or two staff members who were close to patient show up, but they have a chance to talk about the experience and share their concerns and feelings," he says. "All members of the palliative care team have also increased the level of communication with the bedside nurse."
Because the day-to-day nurse is typically not involved in setting the goals of palliative care and might not be aware of the reason that patients and family members make certain decisions, the nurse feels more distress, Fromme explains. "By including nurses, and in some cases, therapists in the loop, they understand what is happening and why and can deal more easily with the case," he adds. "This is an important way to show nurses that we respect their part in the patient's care."
Reference
1. Smith AK, Earle CC, McCarthy EP. Racial and ethnic differences in end-of-life care in fee-for-service Medicare beneficiaries with advanced cancer. J Am Geriatr Soc 2009; 57:153-158.
Need More Information?
For more information about palliative care programs, contact:
Erik Fromme, MD, Assistant Professor of Medicine in the Division of General Medicine and Geriatrics, Director of the Oregon Health and Science University Palliative Care Research Program, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Mail Code L217, Portland, OR 97239. Telephone: (503) 494-3152. E-mail: [email protected].
Gregory Gramelspacher, MD, Director of Palliative Care Program, Wishard Health Services, 1001 W. 10th St., Indianapolis, IN 46202. Telephone: (317) 639-6911. E-mail: [email protected].
John Morris, MD, Medical Director of Palliative Care and Vice President of Clinical Outreach, Four Seasons, 571 S. Allen Road, Flat Rock, NC 28731. Telephone: (828) 692-6178, ext. 347. E-mail: [email protected].
This is the first part of a two-part series about best practices in palliative care programs.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content