Collaborative project tackles palliative care
Hospital fund, RAND, IHI join forces in NYC
A partnership comprised of The United Hospital Fund in New York City; The RAND Center to Improve Care of the Dying in Arlington, VA; and the Institute for Healthcare Improvement (IHI) in Boston is working with 21 New York City hospitals, nursing homes, hospices, and home health care agencies to improve care for people with advanced chronic illnesses and those at the end of life.
That partnership, the Palliative Care Quality Improvement Collaborative, is charged with the goal of achieving measurable change in how each of the participating organizations provides palliative care. It will work to define which practices are to be changed and how, and determine how to measure quantitatively the effectiveness of the change.
"In 1996, we began working with health care providers, predominantly hospitals, to help them to implement serious initiatives for palliative and end-of-life care," says David A. Gould, PhD, senior vice president of the United Hospital Fund (UHF), a health research policy analysis and philanthropic organization focused on improving health care in New York City. With some small grant initiatives, the fund was able to identify champions who took on the challenge. "We are very proud of what we did," he says. "But we wanted to find a way to engage more health care organizations."
Gould had been impressed with IHI’s approach to quality improvement and was aware of national RAND/IHI collaboratives. "We were interested in recasting that model as a regional initiative," he explains.
Getting started
After a series of discussions, RAND officially was called in as a consultant to UHF. "We started brainstorming in late 2000," recalls Sarah Myers, MPH, associate social research analyst with RAND. The model they used, developed, and adapted for health care by IHI, follows the "Plan, Do, Study, Act" cycle.
Potential participants applied directly to UHF. "They were looking for people who had the aim in mind to improve care and demonstrated an organizational commitment, and who could put together a team to work on this over a nine-month period," Myers says. Of the 21 participants selected, 11 were hospitals.
"We realized if we restricted the project to New York City, it would reduce the expense of travel and make it easier for smaller organizations to participate," Gould says. "We sent invitations to all hospitals but to only a select group of nursing homes, agencies, and hospices." To make participation more attractive, UHF awarded a grant to help underwrite a significant portion of the cost of participation.
Targeting change
Based on data generated in earlier collaboratives, it was determined that several issues would be addressed by all participating organizations. They include:
- pain reduction;
- improved advance care planning;
- improved continuity of care between the hospital and nursing home;
- better follow-up on referrals for hospice care;
- patient/family education;
- patient/family communication.
"These are broad domains — areas that teams in our national collaboratives focused on and have amassed the most expertise in, and shared with the teams," Myers explains.
At the beginning of the project, all participants were given some interviewing tools and exercises in their pre-work packages to help them diagnose additional targets for change. For example, they would be asked to call 10 families of patients who had died recently and ask them what else could have been done for their loved one. "A lot of the answers they had anecdotal evidence for, or they knew on their own, but we asked them to think about what they would find unsatisfactory if they were a patient," Myers says. The teams also had expert faculty available to them for consultation.
The framework for the questions were RAND’s seven promises a health care system should be able to make to someone nearing the end of life, Myers says. (See box, below.) "Some of those promises can be kept now, and some eventually, but a system should be able to promise these things to a patient," he says. "If they can’t, they should think about how they can get in the position to make those promises."
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7 Promises Health Systems Should Be Able to Make 1. Good medical treatment: You will have the best of medical treatment, aiming to prevent exacerbation, improve function and survival, and ensure comfort. 2. Never overwhelmed by symptoms: You will never have to endure overwhelming pain, shortness of breath, or other symptoms. 3. Continuity, coordination, and comprehensiveness: Your care will be continuous, comprehensive, and coordinated. 4. Well-prepared, no surprises: You and your family will be prepared for everything that is likely to happen in the course of your illness. 5. Customized care, reflecting your preferences: Your wishes will be sought and respected, and followed whenever possible. 6. Use of patient and family resources: We will help you consider your personal financial resources and will respect your choices about using those resources. 7. The best of every day: We will do all we can to see that you have the opportunity to make the best of every day. Source: Americans for Better Care of Dying, Washington, DC. Web site: www.abcd-caring.org. |
Each team was asked to answer the following questions:
- What is your goal, and what do you want to accomplish?
- How will you know a change is an improvement?
- What changes can we make that will result in improvement, i.e., what can we do differently?
"Every month, the teams review the data to see what else they need to do," Myers notes.
"If we’ve been surprised by anything, it’s been the ability of the organizations to internalize the change model and to really come to believe it in a relatively short period of time," says Gould. "In the last few weeks, we had a comment from one of the nursing homes who said it’s the most significant vehicle for change because it got everybody excited."
Once the practice changes have been identified and put in place, the participants will look to spread them to other parts of their organizations, Myers says.
However, Gould adds, that’s only the beginning for UHF. "We need to identify how many participants want to continue another year, and bring on the next generation as well," he says. "Having done this, we will take a real hard look at the model and how it might be used to begin change practices, say, in ambulatory care."
For more information, contact:
• David A. Gould, United Hospital Fund, 350 Fifth Ave., 23rd floor, New York, NY 10118. Telephone: (212) 494-0740.
• Sarah Myers, MPH, The RAND Center to Improve Care of the Dying, 1200 S. Hayes St., Arlington, VA 22202-5050. Telephone: (703) 413-1100, ext. 5460. Web site: www.medicaring.org.
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