Palliative Care Programs: The Challenges of Growth

Gratifying Aspects of Growth

Christine S. Ritchie, M.D., MSPH: On the basis of what we have heard, it seems that every one of your palliative care programs has experienced fairly significant growth, with some experiencing more plateauing than others. I look forward to hearing how you have managed some of those challenges, but would first like to know what have been the most gratifying elements of the growth of your palliative care programs.

Sharol Herr, R.N., B.S.N., MSEd: The most rewarding aspect of our program has been its real impact on the quality and satisfaction of patients, their families, and the staffs with which we are working in hospitals, and the satisfaction in working with our collaborating physicians. We have demonstrated that we can truly integrate into the larger healthcare system and be seen as partners in their care of patients and as a critical part of the healthcare picture.

Lori Yosick, LISW-S: I feel the same way and especially that we are finally being viewed as part of the fabric of the system at a time when our system and its three hospitals are expanding their programs. We used to ask, “Hey, what about us?” Now they are calling on us to be part of their planning. It's good to get invited to decision-makers' meetings before they make decisions.

Todd R. Coté, M.D., FAAHPM, FAAFP: Our experience has resembled what Sharol has described about Mount Carmel's experience. There is nothing better than working as part of a team and feeling that you're actually getting your service to the people who need it. But achieving that change in culture is a hard uphill struggle, partly because of the historic view of palliative service, and it is therefore really quite rewarding when you see referring physicians promoting planning for palliative care to patients and their families.

Lyn Ceronsky, D.N.P., G.N.P., CHPCA: Just as what Sharol described for Mount Carmel, at Fairview we have been invited to be part of the solution to some of the dilemmas now facing all healthcare facilities, as our healthcare system thinks about how to deliver comprehensive care and address the management of chronic diseases. The invitation to the palliative care team to sit at the planning table for both inpatient and outpatient care makes the team recognized for their work.

Steven Z. Pantilat, M.D.: Our growth over the past 6 or 7 years has been primarily in working with patients who are discharged, rather than with patients who are in the hospital. In our first year, approximately 80% of the people we saw died in the hospital and we were very much an end-of-life or brink-of-death type of service. That has changed dramatically, to the point where the vast majority of our patients leave the hospital, and only 35% die in the hospital. That has been due to a very specific effort on our part to become involved earlier in the course of a patient's illness.

The other area of our growth has been with patients who have diseases other than cancer. For example, we are seeing increasing numbers of people with cirrhosis and end-stage liver disease, cardiac disease, pulmonary disease, neurologic illness, and cystic fibrosis, and much of our educational outreach efforts have been directed at physicians and nurses caring for those patients.

Thomas J. Smith, M.D., FACP: The most gratifying element of our palliative care program has been to increase our service. We had always been a fairly upstream service in the course of patients' illnesses, but we are now very much integrated into the program at our cancer center. Thus, while the cancer center thinks about expanding clinical trials, for instance, it now also conducts research in pain and symptom management. We can help get people tuned up so they can get more therapy and we are welcomed on the bone marrow transplant unit because we can improve functional status.

Christine S. Ritchie, M.D., MSPH: Are they looking to you to help support that part of the research mission?

Thomas J. Smith, M.D., FACP: Absolutely. The National Cancer Institute primarily approves funding for a cancer center on the basis of its existing grant funding and publications and intraprogrammatic work, and the more research funding you have the broader can be the research funding across your university and in the surrounding community. It also allows greater patient enrollment, and there are many symptoms of disease and its treatment that still need work.

Christine S. Ritchie, M.D., MSPH: Are there other aspects of the growth of palliative care that have been particularly gratifying to you?

Sharol Herr, R.N., B.S.N., MSEd: I think it has been exciting to watch the interdisciplinary team members at our hospitals, including case managers, social workers, and pharmacists, become expert in palliative care; they have demonstrated a real initiative for acting as specialists in such care.

Todd R. Coté, M.D., FAAHPM, FAAFP: Through the PCLC program, we have been delighted to contribute to the training of at least 23 or 24 palliative care teams from hospitals in Kentucky. It gives us the sense that we are contributing to the public good as well as to individual patient care.

I also wanted to remark on what Steve said about final end-of-life care and dying patients. One of our most rewarding experiences, particularly at our university-based hospital, is to be able to serve dying patients who will not be leaving the hospital. That has been so true that we are developing a separate hospice service for these patients that is well-coordinated between our palliative care center and the University of Kentucky.

Difficult Aspects of Growth

Christine S. Ritchie, M.D., MSPH: What have been some of the most difficult aspects of the growth of your palliative care programs?

Lori Yosick, LISW-S: Finding and retaining staff has probably been the most difficult aspect of our experience. Our system has the blessing and the curse of being large. We have many layers of processing in recruiting, interviewing for, and offering positions. We're having ever-fewer fellowship-trained, board-certified, and experienced palliative care specialists coming into the field, especially physicians and now nurse practitioners, and we have a couple of other, competitive providers in our community. We find that people come in, are interviewed at their sites and ours, and that the other two systems make them an offer on the spot. It's not just a process of trying to recruit and retain people, but also of finding the people that are the best fit for our team.

Lyn Ceronsky, D.N.P., G.N.P., CHPCA: I echo that. In some ways we are victims of our own success, in that either in our local area or over our wider region, the growth of palliative care programs means more competition, and the supply of suitable candidates is not adequate to meet the need for new personnel.

Apart from that, when as an administrator I think about the growth of palliative care, I am always thinking about whether a staffing need can be met by education or by a process change to meet the specific needs of palliative care patients.

Steven Z. Pantilat, M.D.: One of our challenges is that the cycle through which our medical center responds to requests for support leaves us in a constant state of “catch-up.” It has been very hard for us to get additional resources in anticipation of growth. We are much more likely to get them in response to growth.

The result is that we are almost always running very thin in terms of our staffing needs. It has also been hard to find qualified people. Hiring physicians has not been simple, even though we think we're in a really nice, if costly, place to live, and have a good program. But as Lori and Lyn have observed, there is a lot of competition out there.

Todd R. Coté, M.D., FAAHPM, FAAFP: From an economic standpoint, the more we do the more we lose in reference to growth. In the healthcare service industry you would think that growth would lead to economic rewards and even to profitability, and certainly to sustainability. But in our community it seems that as we continue to grow and work hard toward sustainable growth, we continue to struggle financially, to the point at which we have to try to negotiate funding support from our collaborative hospitals and universities, particularly for the physician components of the palliative care teams that we service.

Sharol Herr, R.N., B.S.N., MSEd: It has also been a challenge to maintain the education and presence of palliative care personnel. Because of constant staff turnover in our hospitals, with new physicians and new administrators, our clinicians work really hard to meet all of our needs and provide all of our consultations at the same time. Our educational effort is never done, and neither is our marketing.

Christine S. Ritchie, M.D., MSPH: Do you still have to provide a lot of internal education to your leadership and internal stakeholders?

Sharol Herr, R.N., B.S.N., MSEd: Yes. Because of turnover, new staff, and the bedside staff who care for the patients, you need to provide constant mentoring and assess what they need for taking the best care of patients.

Thomas J. Smith, M.D., FACP: In terms of difficulties with growth, I would echo what we've heard about its financial aspect. Although we're a state-assisted center, we do not really get that much support from the state, and so have to earn our salaries. And that is very difficult in hospice and palliative medicine when you essentially have to pay a 40% tax to the department and medical school, because it means that you have to earn twice as much money before you can start supporting yourself on your salary. And that has hurt us in our ability to keep on growing. I do not think it's recognized that every time we receive a patient at our center, all of that patient's care is transferred to us, so we gain the oncology, radiation, surgery business, etc. As I had mentioned earlier, we're always running one step behind.

We have not been successful in the past few years in pointing out to our healthcare system's authorities that we are growing, that we bring in new patients through the hospital pain clinic whose cancer care is then switched over to us, or that we save money for the hospital. Palliative care saves the center over $1 million a year.

Christine S. Ritchie, M.D., MSPH: Have you had challenges to your recruitment in disciplines other than medicine?

Thomas J. Smith, M.D., FACP: We have recruited very nicely in terms of PhD-level people for social and behavioral medicine, and of health administrators, but we haven't been given the green light to recruit more physicians in palliative care because our administrators don't see that as possibly being highly beneficial for them in terms of revenue.

Lyn Ceronsky, D.N.P., G.N.P., CHPCA: We have found it equally challenging to recruit advanced-practice nurses. There are no programs in our geographic area that prepare nurses specifically for palliative care, despite a host of opportunities for graduates currently pursuing positions in this field.

Thomas J. Smith, M.D., FACP: We have had less trouble maintaining and retaining people than we have had in recruiting new people. Over the past 10 years we have had incredibly little staff turnover in our inpatient palliative care unit. Some of the nurses who began working with us 10 years ago are still working with us, and so are most of the physicians who began working at our facility. However, I think we could recruit very well if we were allowed to use the resources that we generate. For example, our division makes a large profit. If we could keep that instead of supporting other divisions, we would be able to recruit. But that is hard on other divisions.

Christine S. Ritchie, M.D., MSPH: It seems that for some programs, the challenge is to find the resources on which to base new recruitment, while for others it is finding the individuals to recruit. Have there been other difficult aspects of growth besides those in recruitment, financing, education, and marketing?

Lyn Ceronsky, D.N.P., G.N.P., CHPCA: A challenge mentioned at several sessions of the American Academy of Hospice and Palliative Medicine (AAHPM) Assembly has been to quantify the financial impact of referrals or consultations that lead to a decision to avoid escalating a patient's care or avoid readmission of a patient. Finding a way in the hospital cost-accounting system to determine the financial impact of such decisions remains a hurdle.

Unexpected Aspects of Growth

Christine S. Ritchie, M.D., MSPH: What have been the most unexpected or surprising aspects of your programs' growth and maturation?

Sharol Herr, R.N., B.S.N., MSEd: One of the most surprising aspects of our growth has been the need of the intensive-care unit (ICU) and emergency department (ED) for our services, and their openness to our working with them. They have critical needs that we have been invited to help meet, and we have found that in planning our services we have to factor in those needs.

Steven Z. Pantilat, M.D.: What has been most surprising to me is that the bigger our team has become, the more consultations we have had for palliative care. It almost seems that the greater our presence in the hospital, the more we have added students and residents, a chaplain, and other personnel, the busier we get. Early on in our program, when our census was about 250 patients a year, I was reluctant to accept students and residents who wanted to rotate with us because I felt we might not be able to give them sufficient clinical work. But as our team and our presence in the hospital grew, so did our census, and we had a steady increase in consultations and calls for teaching. It has been a positive feedback loop since then.

Something else that is gratifying is how our marketing and educational efforts contribute to our growth. When we are invited to give grand rounds in neurosurgery or gastrointestinal medicine, or to talk to the liver-transplant team or to cardiologists, we see a sustained increase in consultation calls from those services. Letting them know more about what we do has been very helpful.

Lyn Ceronsky, D.N.P., G.N.P., CHPCA: As clinicians, chaplains, bedside nurses, respiratory therapists, and other professionals have had the opportunity to work with our palliative care teams, it has resonated with their awareness of unmet needs, and we have received a sustained round of applause for our program.

Todd R. Coté, M.D., FAAHPM, FAAFP: Although it may not be as surprising as some of the other experiences mentioned here today, we have had a considerable number of positive responses to our program in the past 2 or 3 years from administrative leaders at all of our hospitals, including CEOs, and from the dean of our school of medicine. I think the national literature on healthcare administration, which has increasingly discussed palliative care, has had an important impact on that.

And we have also developed wonderful relationships with the hospitalist groups in both our community hospitals and university-based hospitals, to the extent that we now have regular dialogues with them. Because all of us live in the same community, we know some of them personally, and that has counted heavily in moving our role forward more quickly, including our role in the emergency room and the ICU, as already mentioned.

We particularly also see this in our community-based practices, from which we have cardiologists and cardiovascular surgeons calling us quite often. Because time is of the essence in today's clinical practice, we usually get their calls only at the end of the day, but we try to accommodate them.

Strategies for Managing Growth

Christine S. Ritchie, M.D., MSPH: What strategies have you utilized to manage these challenges? I would like to start with general strategies and then move to managing some of the specific challenges that we have heard.

Lori Yosick, LISW-S: One of the most important things that we have done both to manage our growth and to keep us growing is to have had a dedicated administrator of our program, which is my full-time job. That visibility as the program administrator, in meetings and elsewhere, has helped to keep a focus on our program and make sure that it retains its importance in our community healthcare system.

Steven Z. Pantilat, M.D.: As far as planning for and insuring growth, nothing is better than doing a good job, and being able to demonstrate it. Collecting and displaying data on patient outcomes and the many different ways in which our team has been able to contribute to our institution has been exceedingly important for us.

And in terms of strategies for growth, the interdisciplinary team has also been important to us. When things get busy, we practice a lot of division of labor. I will see a patient while our social worker and our chaplain are seeing other patients. Everyone can serve a need, according to what is most important for a patient, and report back so we can decide whether another team member also needs to see the patient.

Having an interdisciplinary team is good for promoting growth in other ways as well. Many people contact us because they are seeking help through the social work component of palliative care. But when they do this they get our entire team, and there are invariably services that each member can add. Or they need the chaplain or need the physician. Or sometimes they just need our palliative care swing bed and that becomes our entry point to promoting our services.

A third factor in our growth has been the maintenance of a good relationship with our hospital leadership. We make sure we keep them informed about what we are doing and we are willing to participate in the kinds of activities important to hospital administration, such as, developing policy, speaking to a particular group, or contributing to an initiative. That way we're seen as a team player and a service that cares about more than just what comes our way. And simply reminding them of the impact we are having even when we are not asking them for more resources.

Thomas J. Smith, M.D., FACP: We do not have the luxury of our whole team seeing every one of our patients every day, so one thing we have tried to do is to provide truly useful consultations to the team member who is the first to assess a patient's situation. We try to clarify the issue in question and then, for example, consult with our full-time chaplain if it's a chaplaincy issue. We have also given great attention to our fellows' training and skills, so that after the first month or so they have enough expertise to work integrally with our whole team, listen to the patient, listen to the family, and create a concrete plan of care. That gives me more time to spend on my consultations or other aspects of my work.

And the same has been true for our two advanced-practice nurses, who know a lot more about bedside care and pain management than most of us. I would rather have them speak at a goals-of-care meeting or a pain-management meeting than address such a meeting myself.

Christine S. Ritchie, M.D., MSPH: That strongly suggests that utilizing one's interdisciplinary team can be quite effective in managing growth.

Thomas J. Smith, M.D., FACP: Yes. The problem is that it leaves you with more consultations. We end up doing a fair number of phone consultations. And for people with very modest needs that probably works just as well as having the whole team come in and provide a consultation in person.

Lyn Ceronsky, D.N.P., G.N.P., CHPCA: We have found three further strategies helpful for managing our demands. One is the concept of triaging patient needs according to their urgency. Doing that with a focus on the outcomes we're seeking for that particular patient, discussing those outcomes in rounds, and being willing to sign off or to keep our social worker and chaplain involved for emotional and spiritual support and to report changes to the team, frees our clinicians for urgent symptom management needs.

A second strategy is anticipatory guidance as part of our consultations, so that we address expected needs with planned strategies that can save time and facilitate triage. And a third strategy is having our chaplain, social worker, or an advanced-practice nurse act as liaisons with their own departments, all of whom can act as eyes and ears and bring concerns and issues back to the consultation team.

Sharol Herr, R.N., B.S.N., MSEd: We've also found it important to reassess our processes and modify them as needed. If you use routine sets of orders, are they still relevant? Do you need to reexamine the efficacy of your communications when you are asked to give new consultations? Are you able to modify your hours of operation as needed? We are looking at increasing our staffing on weekends, for example, to expand weekend consultations. Reassessment helps to create flexibility and modify procedures as needed.

And we have also developed and strengthened our relationships with hospices, so that when we discharge a patient, the hospice will already have a plan of care for the patient, and can be mobilized to meet the patient's needs. And that in turn has helped us to address issues relating to length of stay. A further useful strategy has been developing and strengthening our relationships with hospitalist services and demonstrating our value to them in meeting their challenges in managing chronically ill patients.

Christine S. Ritchie, M.D., MSPH: What strategies have you developed for addressing funding and planning for growth?

Steven Z. Pantilat, M.D.: We have found that in trying to anticipate staffing needs and argue for those needs, examining comparable organizations or programs and asking how they are staffed and how many patients they have and for how long, has worked well for us. That has been very useful to us in trying to understand what constitutes a reasonable workload and in demonstrating to our hospital leadership what appears to be normative in other programs like ours. And those data are just a few phone calls or e-mails away.

Sharol Herr, R.N., B.S.N., MSEd: Something that our administrators have done is to maintain an active dialogue with our system's finance department. The administrators have a dashboard that they use for reporting quality as well as financial outcomes and measures, and have modified what is measured and reported on the dashboard on the basis of that dialogue with the finance department. The result is that the dashboard truly reflects our activity and numbers, and helps us in terms of demonstrating needs as they develop and their impact on the service.

Todd R. Coté, M.D., FAAHPM, FAAFP: We are a fairly large practice in both palliative and hospice care. We essentially run everything as if it were a business, and fundamentally look at efficiency and volume, and use those terms quite often and particularly in the world of business economics. And as chief medical officer of our practice I work with our administrative leadership as well as with our interdisciplinary teams, and I think it is necessary, particularly if you grow to a large size, that you look at your service from the business perspective and have very clear guidelines for your practitioners.

Christine S. Ritchie, M.D., MSPH: How have you handled the challenges of recruitment and staffing?

Lyn Ceronsky, D.N.P., G.N.P., CHPCA: I am always recruiting. But I have also tried to keep our senior leaders apprised of how difficult it is to recruit a clinician with experience or an interest in palliative care. This helped to bring in clinicians when our case was still not as strong as I would have liked it to be but when our trajectory of growth was nevertheless clear. I have been fortunate to obtain administrative support for bringing in new personnel when we really needed the help in a very short time.

Lori Yosick, LISW-S: I tapped in with our system's physician recruiters and talked to them specifically about the kinds of physicians and nurse–practitioners we were seeking. And that made them look more specifically for such people. Like Lyn's center, we are always looking for people who have had a fellowship or experience or who express an interest in palliative medicine. We try to meet with them even if we don't have a position immediately available. Fortunately, we have always had some positions available, but whatever your facility's situation at a given moment, you are developing relationships when you meet people, and you may develop a pool of people interested in coming on board with you when the opportunity arises.

Thomas J. Smith, M.D., FACP: We keep trying to discover our interviewees' other interests, so that if they have an interest in research we can put them in that setting, and if they have an interest in education we will steer them that way and set them up to give talks, and the like. But we do not just sit by and let those things come and go; we try to get people involved in a breadth of activities beyond daily patient care, so that they can participate in that care but perhaps also give a talk at a national meeting or present an abstract to a local meeting or do research.

Steven Z. Pantilat, M.D.: A strategy that we are adopting on the physician side and the nurse–practitioner side is to train our own. We have a fellowship in palliative medicine starting this summer, and I am hoping that it will serve as a source of future faculty physicians in palliative care. We also have an outstanding nursing school at the University of California-San Francisco, with nurse–practitioner students, some of whom are interested in palliative care, and we are very happy to have them do rotations with our service, partly as a recruiting tool. We're also happy to work with nurses in our hospital and with social workers and case managers, to train them toward a skill set that will ensure we will have qualified people around if we do get the opportunity to hire.

Sharol Herr, R.N., B.S.N., MSEd: I think that a willingness to be flexible in terms of scheduling is another important strategy for professional recruitment: that not every staff member will have to work on a 9-to-5 basis from Monday through Friday, but that creative staffing models should be considered, in terms of part-time or flexible hours.

Christine S. Ritchie, M.D., MSPH: What is your key take-home message for a program that is facing substantial and challenging growth?

Steven Z. Pantilat, M.D.: Understanding that a good palliative care service will grow, and anticipating that and looking ahead and collecting the data needed to meet that growth, whether financial data, outcome or comparative data, staffing ratios, or other necessary information—will allow you to advocate for the resources you need to address the demands of that growth. Also important are strategies for promoting growth.

We may worry that calls for our consultations will go away, but that has not been our experience here or with the teams we've worked with through PCLC mentoring. Growth is a fact of life. One more thing I would advise is to set limits on expectations, so that people do not expect you to be available nights and weekends if you cannot do that.

Sharol Herr, R.N., B.S.N., MSEd: I think that quality fuels success and that providing high- quality care is the key to an enduring palliative care program.

Lyn Ceronsky, D.N.P., G.N.P., CHPCA: I agree. Keep the focus on quality despite any challenges that growth may bring.

Christine S. Ritchie, M.D., MSPH: Thank you all for a very instructive discussion.