The Intersection of Need and Opportunity: Assessing and Capitalizing on Opportunities To Expand Hospital-Based Palliative Care Services

Kaiser Permanente, Bellflower Medical Center (Kaiser Bellflower)

Kaiser Bellflower is a 240-bed community hospital that is part of a vertically integrated health care system. The medical center had a well-established palliative care home-care program, ¹¹ as well as a hospice, but no inpatient PCS. The Kaiser Bellflower team goal was to develop and implement an inpatient PCS within an integrated health care system.

Three strategies were used to achieve this goal. The first was a top-down approach used to secure support. Hospital administrators were key in conceptualizing the service and supported the effort from the outset. The second strategy was leveraging existing relationships. The physician and nurse members of the palliative care team held clinical and administrative positions that facilitated the rapid development and implementation of the program. Most had extensive experience in providing palliative care in other settings, which led to their rapid acceptance as clinical experts. To promote visibility and acceptance for the PCS within the existing hospital culture, throughout the first year of the program the team met with hospitalists and specialists on a regular basis. Given the existing outpatient palliative care services within the institution, the inpatient team was careful to clarify the scope of their services and their relationship to other programs. Furthermore, the PCS chose to become the point of entry into palliative care, coordinating all palliative care services within the medical center and triaging patients appropriately. The third strategy was securing training and mentoring for the palliative care team. While most team members had previous palliative care experience, none brought expertise in hospital-based PCS. Training provided by CAPC was a cornerstone in launching the program, as was assistance from their Innovations mentor.

The team also recognized the need to document the impact of their new service. They assessed patient, provider and hospital-level outcomes including change in pain and other symptoms, patient emotional wellbeing, and family satisfaction. Focus groups were used to document physician and nurse satisfaction with the new PCS. ¹² Hospital-level variables were those being assessed by the Kaiser system at large, including rates of hospital readmission, access to hospice and home-based palliative care, and length of time receiving these services prior to death. In its first 16 months, the program was able to demonstrate statistically significant improvements in pain and dyspnea and improved care coordination.

Los Angeles County Medical Center/University of Southern California (LAC+USC)

With 737 beds LAC+USC is the largest provider of care to indigent patients in California. The emergency department (ED) serves primarily poor and Spanish-speaking patients. At the onset of Innovations, LAC+USC was completing construction of a hospital that had fewer inpatient beds and a 140-bed ED. Like many public hospitals, a major issue at LAC+USC was prolonged boarding in the ED and the need to reduce hospital length of stay. The small, existing inpatient PCS was generally consulted close to death after a prolonged hospitalization.

Early on the palliative care team leader, who was an ED physician, recognized the unique opportunity to partner with the ED. Hospital utilization data demonstrated that a significant proportion of patients being admitted through the ED were elders with advanced illness, many of whom qualified for direct hospice admission. However, in the absence of services and care planning, these patients typically had no alternative for care beyond ED assessment and admission. Long boarding times in the ED and lengthy hospital and intensive care unit (ICU) stays were further evidence that early involvement could impact both utilization and quality of care. In response to these needs, the PCS created a program of rapid ED palliative care consultation, including Spanish-speaking staff to facilitate communication with patients and families.

The program enjoyed many successes. Before the PCS was anchored in the ED, few patients had the opportunity to discuss advance directives or voice their concerns about dying. The PCS addressed patient and family concerns and initiated goals of care conversations, often in the ED. The ED found the PCS to be especially helpful for trauma cases, where brain or cardiac death was imminent. Presenting options for palliative care and hospice placement are now routinely offered to all appropriate patients prior to hospital admission. Initiating consultations in the ED also allowed the team to provide family support throughout the ED and hospital stay. The team found that patients and families who received early palliative care consultation were more able to participate in decision-making from the start of the hospital stay. For the PCS, becoming involved in the ED was much more desirable. Prior to the innovation, inpatient consultation requests were delayed by many days and meeting patients and caregivers in the final hours of life limited their impact. There were operational benefits associated with earlier involvement, including decreased hospital length of stay and more referrals to hospice. The program was recognized for excellence in patient-centered care by the National Association of Public Hospitals.

St. John's Regional Medical Center and St. John's Pleasant Valley (St. John's)

St. John's includes two community hospitals: St. John's Regional Medical Center with 266 beds and St. John's Pleasant Valley Hospital with 180 beds. Both hospitals are affiliated with Catholic Healthcare West, a large nonprofit, faith-based health care system. At the start of Innovations, St. John's already had an active PCS. However, a needs assessment demonstrated that the service was being under-utilized in a number of locations within the hospital, especially the ICU. When consulted, the PCS successfully facilitated goals of care discussions, but these conversations were happening late in the hospitalization.

St. John's palliative care innovation was to expand palliative care in the ICU, ensuring that their service was available to patients most likely to benefit from consultation. Specifically, they identified critically ill patients for whom the goals of care prior to admission were palliative in nature. Second, they developed criteria to identify clinical conditions in the ICU that most often result in palliative management, such as critical care stay of more than 4 days, or stage IV cancer of any type. Their goal was to help families assimilate information regarding their loved one's condition and address goals of care, facilitate optimal symptom management and provide options for the continuum of care, including hospice.

To accomplish these goals, the PCS solicited the support of the critical care medical directors and nursing leadership, who ultimately approved the use of screening criteria to identify patients in need of PCS consultation. PCS team nurses, chaplains and social workers participated in daily critical care rounds and used a coordinated approach to family conferences and physician communications. The team educated nursing staff regarding the screening criteria through a number of staff development programs presented from an interdisciplinary perspective. Additionally, the team collaborated with pulmonologists, critical care nurses, and respiratory therapists to develop an order set for the withdrawal of mechanical ventilation. This order set provides a consistent process, facilitating the interdisciplinary team's focus on patient comfort and family preparation.

Early outcomes of this ICU-based PCS intervention have been positive. The team documented a 132%, increase in ICU consultations, with 93% including family conferences and high family satisfaction. The ICU focus was associated with a decrease in the number of patients dying in the hospital and an increase in discharges to hospice. Additionally, the team demonstrated that their service led to significant cost savings in the last four days of life and increased family satisfaction. The program was recognized with a Circle of Life Citation of Merit in July 2009.

University of California, Los Angeles Medical Center (UCLA)

UCLA is a large, tertiary care, academic medical center with two major clinical sites that are separated in space and have different institutional cultures. The main academic hospital, Ronald Reagan UCLA Medical Center, now with 668 beds, recently underwent a major renovation that resulted in the loss of 110 beds and resulting capacity issues in the ICUs. The second site, Santa Monica UCLA Medical Center and Orthopedic Hospital, has 337 beds. A prior attempt at developing PCS at UCLA was based at the Santa Monica Medical Center and was not sustained due to lack of acceptance, limited use by the medical center faculty, and an inadequate supply of physicians with palliative care expertise to staff the service. In the ensuing years, UCLA established a large, distinguished and highly successful program in geriatric medicine, as well as a hospital medicine program, which cared for the majority of medical inpatients. In a widely publicized national analysis, UCLA was identified as having particularly high use of health services near the end of life. ¹³ Given the capacity reduction and concerns about utilization, at the time that palliative care was developing at UCLA the institution was motivated to decrease inpatient utilization, particularly in the ICU.

UCLA's approach was to develop PCS at both campuses, to focus on improving outcomes valued by the institution, and to recruit geriatricians and hospitalists to staff the PCS. Due to the large demand for palliative care services and the need to integrate into two different hospital cultures, the team decided to “hire from within,” training interested faculty within each hospital in palliative care. While the majority of the 14 physicians who initially staffed the service lacked certification and experience in palliative care, they were instrumental in allowing the program to integrate into the particular sites and to gain acceptance among the faculty at large. To allow the PCS faculty to develop expertise, the service began with only limited marketing. Faculty development provided formal training conferences by outside experts, journal club, a centralized, Web-based repository for relevant medical literature, and a template for documenting consultations.

To demonstrate value, the service focused data collection on length of stay in critical care units. The team was able to show that patients they saw, compared to others with similar diagnoses, had similar lengths of stay on the wards, but shorter ICU lengths of stay.

VA Greater Los Angeles Healthcare System (VA)

The VA is a 328-bed Veterans Affairs hospital in Los Angeles that has a well-established palliative care program that includes an inpatient consultation service, outpatient clinic, case management program, interdisciplinary fellowship program, and an inpatient hospice unit. ¹⁴ Despite offering comprehensive services that developed over 10 years, only a minority of veterans with advanced illness were referred for palliative care services prior to their final months of life.

To engage patients earlier in the course of illness, the VA program implemented and evaluated a method for identifying patients for palliative care based on prognostication by physicians. The team had recently completed a study of palliative nurse case management that identified subjects based on prognostication by medicine residents at hospital admission. The admission note system that is part of the electronic medical record prompted resident physicians to estimate the patient's 1-year mortality. If their estimated mortality was 25% or more, the resident was automatically offered a palliative care consultation. This system was accompanied by efforts to improve resident prognostication skills through didactic education sessions and regular reviews of prognostic estimates by palliative care experts with feedback to the residents. The innovation was associated with a 42% increase in referrals compared to the previous year, with 32% of all consultations coming directly through the prognostication system.