community-based palliative care in florence · current census of approximately 85 to 105 patients...
TRANSCRIPT
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Community-Based Palliative Care in Rural Oregon
May 3rd 2019
Dr. Stephen Kerner and Donna Becker MSW
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Objectives Discuss ways to develop and sustain community-based
palliative care programs in rural communities.
Explore techniques to address the challenges inherent in rural palliative care.
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The Peace Harbor Community-Based
Palliative Care Program
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The Community Located on the Oregon coast Population:
– Florence = 8,800 people– Mapleton = 918 people– Deadwood, Swisshome = approximately 500 people– Peace Harbor’s patient panel = 18,000
Retirement community – 36.4% of population is over the age of 65-years-old (2010 census)– Volunteerism
Our demographic area – approximately 950 square miles
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Palliative Care ProgramObjectives and Goals
Improve the quality of life for patients and their families Offer compassion, psychosocial, and spiritual support Improve access and continuity of care Provide education to patients and families regarding the disease
process and advance care planning Eliminate and/or decrease needless and unwanted
hospitalizations and Emergency Department (ED) visits Coordinate care with community partners
PresenterPresentation NotesMultiple sources of literature review for program development including CAPC, AAHPM, OHA etc
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Program Scope Available Monday through Friday from 8 a.m. to 5 p.m.
– Offer 24-hour coverage to facility patients only Serving patients in 7 different local facilities (memory care,
assisted living, foster homes) Now admitting the highest need home-based patients
– Usually home bound Serving patients discharged from hospice (no longer
meeting hospice admission criteria) and have significant difficulty getting into the clinic for appointments.
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The Team• Dr. Stephen Kerner – Board-Certified
Hospice & Palliative Care Physician • Marti Manko – Nurse Practitioner• Suzan Larson – Medical Office
Assistant (MOA)• Donna Becker – Medical Social
Worker• Marti Free – Chaplain • Kyla AndrewsMcNew – RN /
Program Manager• Volunteers – 29 current volunteers
PresenterPresentation NotesContinue to develop multidisciplinary team.
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Offer a “primary care” model of Palliative Care– Dr. Kerner resumes as the Primary Care Provider for most of
our patient population• Increases time requirements for patients• Helps patients:
o Less confusion about who to call for whato Helps our team to manage care better – we are tending to all symptoms,
medication needs, etc. Less likely to go to the Emergency Department or the hospital.
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The Volunteer Program Offer companionship, support, and respite care Licensed Massage Therapist Transportation volunteers Office Volunteers Check-In Volunteer Pet Care program
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The Patients Current census of approximately 85 to 105 patients
– 2/3 of patient population resides in a facility– 1/3 of patient population in their own home
Our program has served over 311 patients thus far We have approximately 35 to 40 pending patients at
any given time.– Averaging 8-9 admissions per month.– Averaging 6-7 discharges per month.– Averaging 16-17 new referrals per month.
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Program Success Stories Community Support:
– Before the business plan was completed and approved, we had funding available for the first 2 years of the program (community and staff donations + one grant).
We have an active and thriving Palliative Care Volunteer Program.– Over 1600 hours donated in 2018.
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Completed/revised over 140 Physician Orders for Life Sustaining Treatment (POLST) forms – this assures that patient’s wishes are respected at end-of-life.
We are maintaining sustainability due to Dr. Kerner’s ability to bill for services. As a result, we were able to hire a Nurse Practitioner for our team.
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Increased hospice census and length of stay (LOS)
Chart1
201620162016
201720172017
201820182018
Census
2
3
Hospice Census
14.4
18.4
20.8
Sheet1
Census23
201614.4
201718.4
201820.8
Chart1
201620162016
201720172017
201820182018
Series 1
Column1
Column2
Hospice Length of Stay
65.9
64.6
78.8
Sheet1
Series 1Column1Column2
201665.9
201764.6
201878.8
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Increase in Home Health referrals, census and episodes of care
0
2
4
6
8
10
12
14
16
18
20
1 2 3 4 5 6 7 8 9 10 11 12
Dr. Kerner’s Episodes of Care
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• Reducing unnecessary Emergency Department visits and hospitalizations• If a facility calls with an urgent patient need, Dr. Kerner
can usually arrange to see the patient either the same day or the next day.
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Reduction in Emergency Room Visits and Hospitalizations –patients from local facilities
0
5
10
15
20
25
30
35
2014
0720
1408
2014
0920
1410
2014
1120
1412
2015
0120
1502
2015
0320
1504
2015
0520
1506
2015
0720
1508
2015
0920
1510
2015
1120
1512
2016
0120
1602
2016
0320
1604
2016
0520
1606
2016
0720
1608
2016
0920
1610
2016
1120
1612
2017
0120
1702
2017
0320
1704
2017
0520
1706
2017
0720
1708
2017
0920
1710
2017
1120
1712
2018
0120
1802
2018
0320
1804
2018
0520
1806
2018
0720
1808
2018
0920
1810
Outpatient Observation Inpatient
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Palliative Care:The Challenges of Rural
Communities
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The Challenges Staffing and Resources
– Recruiting Palliative Care Team Members in rural settings– Striving to offer interdisciplinary support– Offering coverage that meets patient’s needs and team goals– Time – optimizing the skills and time available with small teams– Funding (staffing, supplies, operation costs, etc.)– Accessing medical services (labs, imaging, etc.)
Working with several Electronic Medical Records (EMRs)
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Managing referrals– Creating capacity to manage new referrals and current patients
Demonstrating Program Value– Tracking statistics and metrics– Balancing value-based services in a fee-for-service world– Patient Experience Surveys
Education– Providers and staff– Community partners and facilities– Community
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Addressing the Challenges
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Staffing and Resources Recruitment
– It took our team 18 months to recruit a Nurse Practitioner– Finding qualified providers
• Willing to train the right candidate
Striving to offer interdisciplinary support to our patients– Started with physician, social worker, and medical office assistant– Recognized the need to offer comprehensive services:
• Added a chaplain to our team with Foundation funding• Advocating for nursing support• Advocating for mobile labs and imaging
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Offering coverage that meets the patient needs and team goals– Able to offer 24-hour support to facility-based patients only– Recruited 2 other providers to help with call schedule– Still unable to offer 24-hour support to home-based patients
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Time – optimizing the skills and time available with a small team in a rural setting– Maintaining regular contacts with patients
• Assuring that a team member is connecting with patients on a regular basis (telephone, in-person visits)
– Formed collaborative relationship with Mobile Integrated Healthcare worker (Community Paramedic)
• Works with our team one day per week and “as needed” during the week– Formed collaborative relationship with clinic nurse care
coordinator• Works with our team one afternoon per week
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– Formed collaborative relationship with local surgeon – willing to do home visits
– Use of Volunteer Program:• Respite and companionship volunteers • “Check-In” Volunteer
o Calls all home-based patients/caregivers once per week o Uses a “call script” to assess for needso Helps to identify patients with more urgent needs (medications, new symptoms,
etc.)
– Travel time• Grouping visits – rounding at the facilities on specific days, seeing
several patients in the same vicinity on the same day
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Funding– Community Support – continue to receive regular donations for
our program– Dr. Kerner and Marti’s ability to bill for services– Ongoing relationship with Peace Harbor Foundation to access
support for highest needs (i.e., chaplain)– Continuously looking for funding opportunities including private
donations, grants, collaborative relationships with our CCO
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Improving patient access to medical services– Mobile Integrated Healthcare worker has been drawing labs for
all home-based, homebound patients– Exploring ways to offer mobile phlebotomy, laboratory and
imaging services– Our program belongs to a larger healthcare system – specialists
including Cardiology, Urology, Oncology, etc. come to Florence on a regular basis.
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Electronic Medical Records Dr. Kerner has to work with several EMRs – our program’s
EMR, local facilities each have their own EMR, and our Home Health and Hospice team has their own EMR
Difficulty with Medication Reconciliation, getting updated notes, etc. – our Medical Office Assistant is constantly requesting records and updating our EMR
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Managing Referrals Receive 13-16 new referrals every month
– Increased awareness of the program in our community Wait list – continued to grow during 2018
– Recognizing the need is higher than expected
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Referral sources– Approximately 35-45% from Primary Care Providers, 20-30%
from local care facilities • Education regarding appropriate referrals• Education about the wait list• Contact all referrals to inform them of the wait list• Urgent situations – can usually see them within a few days
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Establish eligibility criteria and defining population to serve– Started slow – facility patients only and hospice discharges
• Gradually added highest need home-based patients o Homebound and cannot access medical careo Patients without a Primary Care Providero Frequent Emergency Department visits and hospitalizations
– Use a Screening Tool to help prioritize patients– Continuously re-evaluating eligibility criteria and discharging
patients who are no longer appropriate.
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– Recommend completing a Community Needs Assessment to define program criteria; assure you are meeting the needs of the target population.
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Demonstrating Program Value Continuously tracking program statistics and metrics
– Using volunteers for data entry– Running quarterly and annual reports
• Assuring this information is distributed to people who need to see it
Balancing value-based services in a fee-for-service world– Support from administration
• Providing more community-based services• Goal of eliminating unnecessary and unwanted ED visits• Preventing hospital readmissions
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Completed a 12-question Patient Experience Surveys– Received positive feedback regarding what is working well and
where we need to make some changes– Will continue to do annual surveys
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Education Accepting offers for community education
– Completed over a dozen presentations about Palliative Care• Community organizations, faith communities, etc.• Provider meetings, clinic staff, hospital staff• Facility staff meetings
– Balancing increased community awareness with rising number of referrals
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Community-Based Palliative Care in Rural Oregon�ObjectivesThe Peace Harbor �Community-Based�Palliative Care Program The CommunityPalliative Care Program�Objectives and Goals Program ScopeThe TeamSlide Number 8The Volunteer ProgramThe Patients Program Success StoriesSlide Number 12Slide Number 13Slide Number 14Slide Number 15Reduction in Emergency Room Visits and Hospitalizations – �patients from local facilitiesPalliative Care:�The Challenges of Rural CommunitiesThe ChallengesSlide Number 19Addressing the ChallengesStaffing and ResourcesSlide Number 22Slide Number 23Slide Number 24Slide Number 25Slide Number 26Electronic Medical Records Managing ReferralsSlide Number 29Slide Number 30Slide Number 31Demonstrating Program Value Slide Number 33Education Slide Number 35