outpatient palliative care - coalition for compassionate care
TRANSCRIPT
Outpatient Palliative Care: Examining the Impact of a Community
Hospital’s Program
Vincent Nguyen, DO, CMD Mona El-Kurd, MSW, LCSW, ACHP-SW
CARES Team Hoag Memorial Hospital Presbyterian
Objectives
• CARES program description and evolution
• Access points to CARES in the medical continuum
• POLST integration with CARES
HOAG Palliative CARES
Vincent Nguyen, DO, CMD
Program Director
Palliative Care Defined
• Specialized medical care for people with serious & life-threatening illness.
• Goal : comfort care/quality of life
– Symptom management
• Provided by a team
– Person & family = treatment unit
• Appropriate at any age and stage in a serious illness
• Can be provided together with curative treatment.
2011 Public Opinion Research on Palliative Care: Support Provided by the
American Cancer Society and the American Cancer Society Cancer Action Network .
Hoag Hospital
Irvine, CA
Hoag Hospital
Newport Beach, CA
HOAG’s Mission
“…as a non-profit, faith-based hospital is to provide the highest quality healthcare services to the communities we serve.”
Patient
ED
Hospital PCP
SNF
POLST
His
tori
cally
Care Model
• Interdisciplinary care team: – 1 CNS (Clinical Nurse Specialist)
– 3 LCSWs
– 0.5 Chaplain
• Physician order often not required • Consultative: recommendations to
primary provider for consideration to implement.
Common Reasons for Consultation
• Manage complex pain/symptom problems
• Establish patient-centered goals of care
• Support physicians in complex decision making (e.g. tube feeding, withdrawal of dialysis)
• Support for family/patient in distress
• Collaborate with Case Management in the transition process across care settings (e.g. hospital to home with palliative/hospice support)
Clinical Nurse Specialist Symptom Control Consult Service
Mrs. M.
• 70 y/o F with diffuse large B-cell non-Hodgkin lymphoma – Treatment in the outpatient cancer center with
first line chemo, hydration, blood transfusion and XRT.
• Complains of sharp left flank pain, dull achy pain in lumbar spine, abdominal bloating with spasmodic pain, poor sleep, and anxiety
How does CNS help Mrs. M?
• Referral from Dietician at Outpatient Cancer Treatment Center (OCTC) to CNS housed within center.
• Patient reports
– “treatments have been ‘brutal’ and is hopeful for improved quality of life”
– having a positive outlook for prolonged life and possible clinical trial
– not been able to achieve any permanent pain relief
Mrs. M, continued…
• CNS completes pain and symptom assessment; discusses coping, mortality and hopes for the future – Education: routine medication vs. “chasing the pain” – Recommendations for pain/symptom management – Communication to Oncologist for scripting
• Patient reports pain issues resolved overnight, remaining symptoms improved greatly over next few days – Continues to work with CNS and PC LCSW for on-going
needs and support
Care Model
• Expansion: Physician/RN/LCSWs/Chaplain
• Physician-order required
• Consultative: recommendations to primary provider for consideration to implement.
• Co-Management: Orders are implemented independently, but primary provider is notified of recommendations.
Hoag CARES Team (949) 764-8585
CARES = Palliative Care at Hoag
• C = Counseling and Comfort for patients & families
• A = Assistance with Advance Care Planning
• R = Relief from pain and suffering
• E = Education about care options
• S = Support for family members
CARES Brochure
CARES Team Mission Statement
• Provide on-going education, support and consult to healthcare professionals, seriously ill patients and their families to minimize suffering and improve quality of life.
CARES/PC Access Points
• Symptom Management Clinic at Hoag’s COTC - CNS
• Inpatient consult service at Hoag (Newport Beach and Irvine) – CARES team
• Community Palliative Care Program o Telephonic care coordination – LCSW
o Outpatient clinic – LCSW; Physician February 2013
Health Care Reform
Improving care
Improving experience of care
Lower total cost of care
Care of the Seriously Ill Is Often Poorly Coordinated
• Multiple consulting physicians
• Poor communication with patient/family
• Lack of realistic prognostic information
• Lack of clear medical goals
• Poor pain/symptom management
24
The Palliative Care Pulse of California
• Disparity exists – what is said and what occurs
• 8/10 would want to speak to their Doctor about EoL care if they were seriously ill
– 1/10 actually do
• 82% say it is important to put their wishes in writing,
– less than 25% have actually done so
• >50% say they have not talked with a love one about the care they want at the EoL.
CHCF 2011
Medical Care at the End of Life: A Bad Deal
• 25% of Medicare spending each year on 5% of
people who die
– 50% cost on last 2 months of life.
• Despite high spending, quality of care is poor
– People receive care
• They do not want
• From which they cannot benefit
– People fail to receive care
• They do want
• From which they will benefit
Palliative Care in the Era of Health Care Reform
Primary Benefits Helps doctors, patients and families set realistic goals
Improves communication between patient/family and health care providers
Improves pain/symptom management
Improves patient/family satisfaction
Secondary Benefits Reduce ICU length of stay
Reduce hospital mortality
Reduce hospital cost
Reduce hospital readmission
27
POLST Implementation: An IPA Experience
PCP-POLST Pilot Project 5/10/2009 - 10/31/2010
• Engaged 41 exclusive PCP providers – 40% of total IPA Seniors membership
• Seniors Selection criteria: – 10% of the “sickest”, per PCP
Risk Adjusted Factors >= 2.0 Inpatient admissions (1-3 admits in past 6-12 months
• 569 members identified
IPA - PCP POLST Audit 2010
259 of 569 “completed” POLST; 35 PCPs Noted
Section A: DNR/AND (202) 78.0%
Section B: Comfort Measures or Limited Additional
Interventions (190) *Option to transfer to acute if comfort needs can NOT be met at present location
73.4%
Section C: NO Desire for Long Term Artificial Nutrition by
Tube (239)
92.3%
POLST is effective in reducing unwanted hospitalization & medical intervention
Journal of the American Geriatrics Society, Volume 58, Issue 7, 2010. Pages: 1241–1248.
How effective is POLST in decreasing hospital utilization for IPA members?
POLST Incompletion and Hospital Admissions
109
575
113
635
0
100
200
300
400
500
600
700
Total Adm Adm/1000
Inpatient Utilization for 310 Senior Members Recommended to have a POLST but did NOT complete
6 mos pre 10/31/2010
6 mos post 10/31/2010
10.4% increase
10.4% increase
Cut-off date of study October 31, 2010
POLST Completion and Hospital Admissions
71
758
60
655
0
100
200
300
400
500
600
700
800
Total Adm Adm/1000
Inpatient Utilization for 259 Senior Members with Completed POLST
6 mos pre POLST
6 mos post POLST
14 % decrease
Cut-off date of study October 31, 2010
Key learnings:
– Buy-in from Stakeholders o POLST = preferred tool to document conversation
o Not an event but as part of routine care
– Local data
– Align financial incentives
– Reduce cumbersome process
o Ease of access to POLST document
o Paper form & Electronic storage
Working with Frontline Staff to Integrate Palliative Care into Daily Practice
• Emphasis placed on: – Language choice
• “specialized medical care”
• “stress of a serious illness”
• “extra layer of support”
– Knowing access points
– Knowing roles of clinicians
– Starting with the low hanging fruit • symptom management may be an easier place to start
than “goals of care” and advance care planning
CARES Referral ...What to say?
• “Service is a benefit that HOAG provides to those with serious illness.”
• “Allows you and your family to have access to a
team of consultants who provide a layer of support for you. They also serve as an extra eyes and ears to the treating medical team.”
• “Purpose of this service is to: – relieve your pain & symptoms, – listen to what is important for you, – understand your ultimate goal for your present
condition and future decline in health.”
Community CARES/Palliative Care Program Prevents Hospital
Readmission
Mona El-Kurd, MSW, LCSW, ACHP-SW
Historically
• Patients were discharged from the inpatient setting after having had palliative consultation around goals of care, symptom management and end of life counseling without further follow-up from the acute care setting in the community.
Our Beginning
• Community Palliative Care Program - created in January 2011 to expand the continuity of care from a thriving inpatient consult service.
• Purpose - to ensure that goals of care and quality of life addressed during the transition across care environments.
Method
• One full-time LCSW dedicated to outpatient care
– average of 150 patients
– manage via telephone and/or in-office meetings
• Physician order is not required.
• LCSW attempts to see patients who are readmitted to the ER or as inpatients.
Documentation
• Interventions are documented on paper.
• If patient is an inpatient or actively receiving treatment at the Cancer Outpatient Treatment Center (COTC), documentation is completed in EMR and placed in paper chart.
• Outpatient EMR development in progress.
Interventions
• Create a supportive relationship for the purposes of providing:
– Counseling
– Advance care planning/goals of care
– Referrals to community resources
– Facilitation of MD orders for Home Health, Hospice, outpatient services (hydration, etc.)
Frequency of Contact
• Initially, all patients/families were contacted at least 1X a month.
• As volume increase, patients are contacted a minimum of 1X a month for the first 3 months and a minimum of quarterly after that.
• Will some patients be discharged? This is still being assessed.
Referral Sources
• Inpatient - Initially, all discharged patients with an inpatient consult were given follow-up (unless they go to Hospice).
o Now, it is case by case as determined by team.
o Triggers are being developed.
• Hoag Staff - Hospitalists, Case Managers, Nurse Navigators, Community Physicians, CARES Team Members
• Hoag Community - self-referrals, families, friends, other community agencies
Referrals to Community CARES/PC Program 2012
Referral Source
# of Patients
Total Percentage of Patients
Inpatient
169
59%
Hoag Staff
89
31%
Hoag Community
27
10%
TOTAL 285
Months Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec TOTAL
New Patients 16 22 27 20 21 10 20 26 28 35 23 37 285
Follow ups on Existing Patients
68 139 116 113 114 72 84 80 75 73 24 12 970
Summary of Graphs
• Program has not been formally marketed in the community.
– 116/285 = 41% are from Hoag Staff or Community,
– 59% are follow up from inpatient referral.
• As of January 2013, more than half of the patients were not readmitted to the hospital.
2013 - February Statistics
• Face to Face Contact (~1 hr/encounter) – New: 18
– Existing: 17
– Total Hours: 33.75
• Telephonic Contact (~20 minutes/encounter) – New: 29
– Existing: 98
– Total Hours: 48.35
Case #1 - Mr. J
• 87 year old white married male referred to inpatient service after a new dx of gliobastoma multiforme.
• Pt discharged to a SNF, then home on Home Health for a few weeks.
• Spouse was difficult to engage after initial phone calls.
• Two months after initial phone call, spouse called in crisis.
Mr. J
• Pt weak, dehydrated, unable to complete radiation.
• Wife wanted to take pt to ER for hydration.
• LCSW arranged orders for hydration at Cancer Center and coordinated transportation.
• Met with patient and wife for the first time during hydration at Cancer Center.
• Provided counseling, dignity therapy and educated about Hospice.
Mr. J
• Patient referred to Clinical Nurse Specialist for symptom management.
• Patient admitted to Home Health with a Palliative Focus.
• After 7 days on Home Health, he was transferred to Hospice and died after 10 days on Hospice.
• He was comfortable and died in his preferred environment.
• ER and inpatient visits avoided and pt and family felt well-supported.
Dignity Therapy
• Opportunity to enhance person’s quality of life by increasing the sense of meaning, purpose and well-being – Maintain a sense of wholeness
– Identify and maintain a sense of pride in accomplishments
– Role identification
– Define illness journey
– Share memories with loved ones through open conversation
Chochinov, H.M., Hack, T., Hassard, T., Kristjanson, L.J., McClement, S., & Harlos, M. (2005). Dignity therapy: A novel psychotherapeutic intervention for patients near the end of life. Journal of Oncology, 23(24), 5520-5525. doi: 10.1200/JCO.2005.08.391
Case#2 - Joanne
• 46 year old white female referred to Community Palliative Care Program by Brain Tumor Nurse Navigator in April 2012.
• February 2010-Diagnosed with Stage III breast cancer, status post double mastectomy & chemo
• December 2011-brain lesions found; began radiation and gamma knife tx
“I need help with something...”
• First phone contact, states symptoms well controlled.
• Planning a Trip
• Ambivalence
• Medication
COHERENCE
• April 2012-July 2012-Building a supportive relationship o Rebuilding coherence, building memories,
honoring her wishes and to continue her community and cultural ties.
o Control vs. Coherence
o Incoherence-lack of clarity and organization
o Synonyms-balance, harmony ,proportion, symmetry, symphony and unity
The Perfectionist With Insight
• Redefine expectations
• Relaxation techniques
• Reviewed Home Health, Home Health with a Palliative focus, Hospice, POLST and mailed literature
• Referred her to legal advocates, massage therapy
• During a phone call after her European trip, she stated, “Am I fooling myself to even have hope…I am not going to get better.”
Sh
Hope and Living Well
• LCSW helped her to redefine the word “hope”.
• Empowered her to ask Oncologist more direct questions.
• Between August and November 2012, she did not return any of LCSW phone calls.
• In December, she was reached by MSW Intern and reported to her, “I am on a chemo vacation with Sally to escape it all……and I don’t want to think about it”.
• Unable to speak to partner (Sally) about her feelings – partner reluctant to discuss feelings.
“It’s Not Going Away”
• January 11, 2013: Patient initiated phone contact
• 8 new lesions.
• Completed gamma knife tx.
• “This is just not going to go away…”
• Asked to meet with LCSW to review her current AD, to complete POLST and review Home Health Palliative and Hospice Care.
Emotional Rollercoaster
• Met 4 days later. She and partner very engaged, humorous and appeared well-connected. Partner more practical than emotional.
• Is continuing to receive Taxol and Xeloda
• “This has been an emotional rollercoaster…..I know I am going to die from this….I just don’t know when…”
• Difficulty reaching PCP for pain issues.
• Declined offer for symptom management.
• Advance Directive placed in EMR.
• POLST reviewed in detail.
• “Why did you call?”
The Power of Hoag Community
• Continued to attend monthly Brain Tumor Support Group.
• “The 2 hours I spend a month here are very precious to me….I get so much from coming here…I need to be able to speak freely….we all do…”
• Continued support from Nurse Navigator.
Challenges
• Pt admitted to Hoag on 2/5/13 with pulmonary embolism.
• She did not call NN or LCSW.
• She called when needed.
• Some patients don’t call and need is great.
• Looking at ways to track readmissions.
She Knew
• 2/25/13-f/u appointment with neurosurgeon. Found to have leptomemingeal mets
• Patient - “Will I be gone in 3 weeks?”
• Nurse Navigator - “Oh no, I don’t think it will be that soon!!”
Integration of CARES
• 2/26/13 - Presented to ER for pain, nausea, vomiting and left eye proptosis.
• She contacted Nurse Navigator and told her she was being admitted.
• LCSW met patient and SO in ER. Pain was a 9-10 when admitted. Now at a 2.
• Admitted for Ommaya reservoir placement for methotrexate infusion.
• Obtained an order from Hospitalist for Inpatient Palliative Care Consult.
• CARES Team followed patient for pain & symptom management until discharge
Benefits and Burdens
• Second day of admission, appointment at NeuroScience Institute for whole brain simulation.
• SO approached Nurse Navigator - “I don’t think I can do this, we are always on the same page and now we are not”. – Afraid to talk to significant other about this.
• Encouraged to share feelings with patient and to discuss benefits and burdens.
Transition
• 2/28/13-LCSW met with patient and SO
oSpoke to CM and asked she obtain order for contracted HH agency with Palliative focus.
oLCSW contacted agency and left information for Supervisor.
oCopy of POLST obtained, placed in EMR and forwarded Primary/Oncologist.
o Plan for f/u at CARES Outpatient Clinic.
Transition
• 3/1/03 - CM only obtained an order for PT. o order for RN obtained from PCP
o Insurance approval not obtained
o Agency to visit without approval
• 3/2/13 - (Saturday PM) - SO called Dr. Nguyen’s to report patient’s increasing pain. Med titrated. Coordinated with HH to refer pt to Hospice.
• 3/3/13 - Pt admitted to Hospice.
Final Transition and The Last Days
• 3/4/13-HH Supervisor stated patient needs would not have been met without CARES Team
• Contacted Joanne at home. States her pain is at a “2”.
• No need for f/u with Outpatient Clinic.
• Pleased with Hospice.
• Hospice CM speaks German and family from Germany arriving in a few days.
Final Transition and Last Days
• 3/12/13, patient died at home surrounded by family and friends at 7:30am.
• SO stated that she is so relieved that she spoke to patient about whole brain radiation and shared her concerns. Also, glad that she took a leave from her work (even though concerned about job) and stated “Now, I will love my job even more, because it allowed me to be with Joanne”.
• Plan is to go to a Beach House for the weekend to honor Joanne.
Joanne
• “I want to thank you on behalf of Kelly and myself…you have made a tough journey simple and you have given us the handholding we need to get through this….we don’t know how to thank you.”
Pearls
• Care across the Continuum is imperative. • Communication, Communication, Communication. • Palliative Care Team needs to use the support and
expertise of others in the continuum. • Collaboration needs to be supported through the
EMR. • If we ask the right questions, people tell us what
they need. • We learn so much from our patients and families.
“To care is first of all to be with the person who is suffering. Therefore, to care means to hear the cry and to be connected
with the pain, confusion, loneliness, the isolation, and the sense of being forgotten before we need to do something about it. And to care is also to recognize how these same
laments exist in our own hearts.”
Henri Nouwen
HOAG CARES
Contacts: