PCQN Exceptional Practices Spotlight

Fall 2016 Conference October 13, 2016

10/12/2016 2

1. ED Consults Queens Medical Center

2. LOS Prior to Consult St. Jude Medical Center

3. AD Completion Honor Health - JCL

4. Pain Improvement Henry Mayo

5. Home Based PC Mission Hospital

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Ilan Bernstein, MD Staff Physician

Pain & Palliative Care

The Queen’s Medical Center

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Queen’s Mission

“To fulfill the intent of Queen Emma and

King Kamehameha IV to provide in perpetuity

quality health care services to improve the well-being of Native Hawaiians and all of

the people of Hawaii.”

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Founded in 1859 by Queen Emma and King Kamehameha IV

Largest private hospital in Hawaii ... 505 acute care and 28 sub-acute beds

Leading referral center in the Pacific

Superior patient care continually advanced through education and research

1,300 physicians on staff

25,000 acute admissions per year

410,000 outpatient visits per year, including 65,000 ED visits

Punchbowl

The Queen’s Medical Center

The Queen’s Hospital, Founded: 1859

The Queen’s Medical Center

PPC Development History

• 1986-2004 Nurse-run Pain Management consultation service • 2003 End-of-Life Task Force • 2004 Pain & Palliative Care Department initiated

1. Pain Management team (4 nurses) 2. Medical Director + palliative care APRN

• 2006 Palliative care social worker added • 2009 Program expansion (2nd MD, 6thAPRN) • 2013 Program expansion (3rd MD, Chaplain resident)

Palliative Care at The Queen’s Medical Center

• Care coordination across settings – Consultation services provided to all inpatient

units and the Emergency Department – Outpatient services at The Queen’s Cancer Center – Close integration with community providers Primary and specialty care providers Hospice and palliative care community providers

Response Time

• In-house staffing 7 days/week • Routine consultations

- Inpatients: within 24 hr - Outpatients: within 1 week

• Urgent consultation requests staffed appropriately – Uncontrolled symptoms and severe caregiver

distress prioritized as urgent – 24/7 telephone support provided when

immediate presence not possible

Emergency Department Consults

0102030405060708090

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2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

ED consultations

PCQN Member Comparison

Presented at CAPC Annual Meeting, Dallas, November 2013

Presented at AAHPM/HPNA Annual Assembly, Chicago, March 2016

Acknowledgements

• Dr. Daniel Fischberg, MD, PhD, whose slides were graciously donated for our presentation today.

Lessons Learned: Palliative Care Consults and LOS

St. Jude Medical Center Palliative Care Service

Fullerton, CA October 2016

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LOS Prior to PC Consult

SJMC = 3.3 days PCQN = 5.4 days

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History of Our PC Service

Inpatient • 2003: Established service with

1 FTE NP focusing on end-of-life support

• 2011: Expanded to 1.5 FTE NPs • 2013: Expanded to 2.0 FTE NPs • 2014: Dedicated board-

certified PC Medical Director • 2016: 0.5 FTE NP weekend

coverage, 1.0 FTE NP, dedicated MSW

Outpatient • 2011: 1 FTE NP • Feb 2014: Established PC Clinic

in Cancer Center • June 2014: Care Passages • 2015: Improved coordination of

inpatient & outpatient PC Services – 1 dedicated outpatient NP,

2 NP’s cross-cover inpatient/outpatient services

Obtaining the Early PC Consult

• Ability of any healthcare provider to consult our PC Service

• PC Nursing Screen (on admission and Q3D) • New group of hospitalists very pro-PC • 13 MD’s with hospice and PC certification

– ED MD’s, ICU intensivists, hospitalists, oncologists

• Awesome PC medical director

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Obtaining the Early PC Consult

• Health system and regional leadership support – New fiscal year/strategic plan with Pain and

Palliative Care service line as a key initiative – Development of CACPA – ACP discussions by PCP’s & Specialist MD’s

• Improved coordination between inpatient & outpatient PC Services

• Extensive in-services and trainings 2015-2016: MD’s, RN’s, CNA’s, community groups

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Obtaining the Early PC Consult • Visibility

– Palliative Care immersion rate • FY’ 17: 13.5% (data through August 2016); target goal 15%

– Coverage 7 days/week – Daily ICU rounds – Daily readmission report – 7d+ LOS report – Weekly outlier meeting – Mortality O/E monthly meeting – Participation on numerous hospital committees

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Advanced Care Planning

HonorHealth John C. Lincoln Medical Center

Phoenix, AZ Rama Kunkle, DO

Becky Gabriel, LMSW

An interconnected network of care

Acute-care hospitals: • Deer Valley Medical Center. • John C. Lincoln Medical Center. • Scottsdale Osborn Medical Center. • Scottsdale Shea Medical Center. • Scottsdale Thompson Peak Medical

Center. Foundations and community services: • Adult Day Care. • Children’s Dental Clinic. • Community Health Center. • Desert Mission Food Bank. • John C. Lincoln Health Foundation. • Lincoln Learning Center. • Marley House Behavioral Health

Clinic. • Neighborhood Outreach and Access

to Health. • Neighborhood Renewal. • Scottsdale Healthcare Foundation.

Specialized patient care: • Breast Health and Research Center. • Greenbaum Specialty Surgical

Hospital. • HonorHealth Medical Group. • Piper Surgery Center. • Research Institute. • Sonoran Health and Emergency

Center. • Virginia G. Piper Cancer Center. • Virginia G. Piper Pediatric Center of

Excellence - Children’s Emergency Center.

• Extensive specialty care physician practices, outpatient treatment and surgery centers, medical imaging and much more.

EPIC Navigator Tab

Tips for Completing Forms

• Ask patient/family if they have MPOA paperwork

• Be available to sit down and complete the paperwork

• Simple form on cardstock • Scan it into the EMR • Platform to discuss code status

Raising Awareness

• National Healthcare Decision Day • Education on where to find the form

on EMR • SW department have increased

completion of forms as well • Staff education on surrogacy law

Health Care MPOA Form

Living Will

Prehospital Medical Directive

Prehospital Medical Directive

Arizona Surrogacy Law

• Spouse (unless legally separated) • Adult child or majority of adult children • Parent • Domestic partner, if unmarried • Sibling • Close Friend • Attending physician in consult with ethics committee

or 2nd physician • Surrogate decision maker can not make decisions to

withdraw nutrition or hydration

California Surrogacy Law

• Spouse • Domestic Partner • Adult Child • Custodial Parent • Adult Sibling • Adult grandchild • Adult Relative with the closest degree of

kinship

Henry Mayo Newhall Memorial Hospital

Pain Improvement

Lisa Ortega DNP, ACNS-BC, RN Palliative Care Program Manager

Pain Improvement: 1st to 2nd Assessment (10/1/2015 – 9/30/2016)

MISSION HOSPITAL: DISCHARGES TO HOME BASED PALLIATIVE CARE

MARGIE WHITTAKER RN MSN

AJIT AHLUWALIA MD

REZA DEHKORDI MD

PEGGY KIRKWOOD ACNP

MICHAEL MONGE MD

MARY NOONAN CHAPLAIN

TONI SHAPIRO LCSW

HOME BASED PALLIATIVE CARE Home based palliative care = home health care on steroids! PC team philosophy

• Those patients who are not quite ready for hospice but could use the support of additional services such as social work, spiritual care

• Goal to allow patient’s to stay in home setting • Able to continue to support medical management • Know the quality and the staff who will care for patient and family • Limited access to palliative care clinic based until May 2016

HOME BASED PALLIATIVE CARE Ease of access through St. Joseph Home Health system-our preferred provider In 2016

• 51% Home based palliative care converted to hospice • 5% Expired on home based palliative care • 44% left home based palliative care for another reason (improved

health, hospitalization, change in location)

• Average length of stay on home based palliative care = 38 days • Range from 2 days to 114 days before conversion to hospice

PCQN MEMBER COMPARISON REPORT

RESULTS