Abstracts from the Center to Advance Palliative Care National Seminar New Trends. Proven Solutions. November 10–12,2011 San Diego,California

1. The Canary in the Coal Mine: Nursing's Role in Integration of Palliative Care in ICU

Topic: Intensive Care Unit

Description:

Palliative care integration faces many obstacles in ICU settings, leading to unnecessary patient suffering, moral and ethical conflicts, high costs of futile care, and nurse burnout and turnover. Critical care in end-stage serious illness results in high moral distress, especially for ICU bedside RNs who believe care to be futile or in conflict with the patient's values. Long regarded as trusted care providers, nurses can serve as the “canary in the coalmine” that identifies unmet palliative opportunities in ICU and thus can serve as catalysts in palliative integration.

The Nursing Moral Distress Scoring tool, developed by this author, allows nurses to identify and score sources of moral distress in caring for individual patients and their families. This provides a basis for discussion among the team and with families, allowing palliative care integration where appropriate.

We believe that through use of this tool, we are realizing reduced ethical conflicts and related suffering at end of life, reduced time to hospice consultation where appropriate, and cost reductions through elimination of futile care. Nurses report a sense of reduced moral distress, and satisfaction in meeting patient care needs. Improved job satisfaction reduces nursing turnover and related costs and promotes higher skill levels and patient outcomes.

2. Time: Why Does It Take So Many People To Take Care of These Patients?

Topic: Measuring Staff Productivity

Description:

Quantifying the specific tasks of palliative care and the time involved in completing these tasks in a metric that resonates with administrative personnel is critical to the on-going institutional support needed for sustaining and growing a palliative care program. A series of time studies has been completed by the medical staff at Akron Children's Hospital Palliative Care Team every 6 months over the last 2 years. These data points provide concrete descriptors of the specific tasks the palliative care medical team completes. Data points are self-reported every 30 minutes over a one-month period and are grouped into 20 identified palliative care interventions/tasks. These studies, including trends over time, have allowed for changes in team interaction and function which have increased efficiency without impact on patient care or satisfaction. This information has also been useful outside the team itself in justifying to the organization the number of staff required to adequately meet the needs of pediatric patients with chronic, complex and/or life threatening illnesses.

This project demonstrates easy, cost effective strategies for quantifying tasks, projects, patient interaction and inter-team communications. Simple data points can demonstrate the impact a team can have on the population of patients they serve.

3. Triggering PC To Reduce Readmissions with BOOST

Topic: Systems Change

Description:

The BOOST project aims to reduce hospital readmissions through risk identification and interventions to mitigate known risks. On admission, all patients assigned to a hospitalist are assessed for risk factors including: polypharmacy and high risk medications, recent admissions, status of chronic illness, psychiatric issues, health literacy, and social support. Interventions include: simplification of medication regimen, teachback, family meetings to establish goals, depression screenings, psychiatric support and palliative care (PC) consults.

PC has collaborated with administration, hospitalists, and nurses to further decrease readmissions. With input from PC, administration has worked with nursing homes and hospital staff to identify and resolve issues leading to readmission. PC teaches hospitalists to lead family conferences and discuss goals of care. Hospitalists document meeting outcomes in discharge summaries according to a template that addresses advance directives, decision-making capacity and future treatment wishes. These outcomes are shared with primary care physicians or skilled nursing facilities upon discharge, with PC or the hospitalists making recommendations for future care that in some cases includes transitioning to comfort order sets. Nurses also collaborate with PC through triggers that allow nurses to request consults when patients have had several admissions for the same diagnosis.

4. Access to Palliative Care in an Acute Community Hospital

Topic: Systems Change

Description:

Access to palliative care services in an acute community hospital presents unique challenges. A physician driven consultation service was instituted in 2008. To enhance access to the service for patients with unmet palliative care needs without physician orders, in 2001 we instituted a caregiver driven primary palliative care assessment in addition to the ordered physician consultation, both utilizing disease and patient-based criteria integrated into routine care for seriously ill and terminal patients.

In order to facilitate a more timely transition through the care continuum, early palliative care patient identification, assessment and communication with providers promotes referrals for primary palliative care assessment and physician consultation, transfers to appropriate levels of care within the institution based on patient choice and care plan with more timely referrals to appropriate palliative care services such as palliative home care and hospice.

Additional attributes of this model include follow-up communication for patients and providers, as well as primary palliative care assessments to outpatient specialty areas, emergency department and aftercare services to facilitate ongoing and proactive care planning as patients transition across care settings to assure patient and provider satisfaction.

5. Transitional of Care for Children after Critical Illness

Topic: Intensive Care Unit

Description:

Health care providers in intensive care settings with clinical experience in symptom management and end of life care do not always seek advice from palliative care specialists. This has been true in our children's hospital where such consults from intensive care settings (NICU, PICU, CICU) have been few. The palliative care team explored areas for improved collaboration. One such area identified involves the transitional care of children who remain seriously ill and in medically fragile conditions following critical illness. An uncertain prognosis, technology dependence including the need for prolonged mechanical ventilation, chronic symptom burden and an anticipated long length of stay trigger consideration for palliative care referral. The palliative care team in a separate inpatient unit coordinates the care of these children. The palliative care team oversees preparation of family members for care of these children. A home mechanical ventilation service has been established as part of the palliative care program. Transitional care after critical illness is an opportunity for collaboration between a palliative care service and an intensive care service.

6. Pediatric Palliative Care Program as Medical Home

Topic: Systems Change

Description:

There has been a significant increase in the number of medically complex children over the past 15 years (Burns K, Casey P, Lyle R, et al. Increasing prevalence of medically complex children in US hospitals. Pediatrics 2010; 126;638-645). A hospital based medical home for children with complex health conditions has been suggested to provide benefits to the child, the hospital, and caregivers (Cohen E, Friedman J, Nicholas DB, et al. A home for medically complex children: the role of hospital programs. J Healthc Qual 2008;30(3):7-15). The majority of referrals to a recently established (two years) pediatric palliative care program in a children's hospital involved coordination of care and symptom management for medically complex children: 69 of 114 (60%) in Year One and 77 of 144 (53%) in Year Two. Other referral categories were oncology, perinatal bereavement, pain management and end of life care. For children dependent on mechanical ventilation a program to educate caregivers in the use of ventilators at home was established. The palliative care team performs the outpatient care of these children. A medical home for medically complex children can be a major argument in proposals to establish hospital based pediatric palliative care programs.

7. Managing Palliative Care Patients in the Emergency Department

Topic: Emergency Department

Description:

Purpose: To help Emergency Department staff identify end stage patients for whom direct admission to hospice or a comfort care only is most appropriate.

Design: Utilizing Evidence Based Practice it was determined that some patients are admitted from the Emergency Department to the acute care hospital with known terminal diagnosis.

Setting: This was implemented in an 88-bed inner city Level 1 trauma center and teaching facility which sees over 100,000 patients a year in its Emergency Department.

Participants: Participants in this project consisted of Emergency Department Nurses, Physicians, Social Workers, Care Coordination, and Chaplain.

Methods: By utilizing a trigger tool developed by the Inpatient Palliative Care Team, Emergency Department Staff are able to proactively identify patients in the Emergency Department who would benefit from a palliative plan of care.

Results: Hospice referrals and advanced care planning in the Emergency Department with a decrease in inpatient admissions has been noted. Patients needing palliative and or end of life care can be identified earlier.

Implications: Patients often experience a delay in receiving comfort care because they are admitted to the hospital rather than hospice. These patients are counted as a hospital mortality when they die, even if they die enrolled in hospice.

8. Outcomes and Impact of Inpatient Acute Palliative Care Unit in an Academic Medical Center: A Novel Approach

Topic: Impact Measurement

Description:

The palliative care service at Montefiore Medical Center averaged 1800 new consultations per year, more than 600 admissions each year to its in-patient unit and about 2000 visits to its outpatient clinics each year between 2007-2010. It has developed integrated models of care with critical care medicineⁱⁱⁱ and is embedded in the emergency departmentⁱⁱⁱ.

The in-patient acute palliative care unit re-designed and expanded to 15-beds in 2007. Physician assistants were trained to work with palliative care attendings and attendings from other specialties such as geriatrics, internal medicine since the unit was designed as an open unit.

We retrospectively examined demographics, admission diagnosis related groups (DRG), length of hospital stay (LOS), discharge status and hospital charge data using data from internal cost accounting databases for consecutive admissions to the palliative care unit between 2007and 2010.

9. Palliative Care: Big Impact in Small Hospital

Topic: Small Hospitals

Description:

Research has proven that Palliative Care (PC) brings tremendous value to a hospital including improving quality, reducing costs, and prolonging survival. According to the Meier & Cassel 2011 article, if PC programs were able to see 5–7% of their hospitals' total yearly admissions, the “financial and quality impact would be immense.”

The question becomes, “Can a PC program in a small hospital meet the challenge of seeing 5–7% of their hospital's total admissions?”

Bozeman Deaconess Hospital (BDH) is a community hospital in Bozeman, Montana, which has 70 staffed beds. The Palliative Care Consultation (PCC) service began seeing patients in 2005. This service is comprised of a comprehensive team (Physician, Advanced Practice Nurses, Masters of Social Workers, Spiritual support, Music & massage therapists). The PCC service has collected data since its inception in all areas including quality, costs, and survival. During its first year in 2005, the PCC service at BDH saw 1.3 % of all hospital admissions, and subsequently this percentage has grown to 6% of all admissions during 2010.

The growth that PCC has experienced is primarily based upon two factors; a team of quality professionals with great work flexibility and strong relationship building with referring providers.

10. Spreading Hospital Palliative Care Services

Topic: Systems Change

Description:

In 2007, a review of California hospitals found only four of California's 17 safety-net hospitals had palliative care services (PCS). The California HealthCare Foundation, in partnership with the Palliative Care Leadership Center at the University of California San Francisco and the Safety Net Institute hypothesized that a cohort-based approach could inspire the creation, expansion, and sustainability of PCS in California safety-net hospitals. In 2008, the California HealthCare Foundation launched the Spreading Palliative Care in Public Hospitals, providing start-up funding for new services and grants to expand established PCS in California public hospitals. Grantees also received training and technical assistance from PC experts; participated in an active Learning Community; collected and shared a common dataset; and contributed to best practices for managing clinical situations and administrative processes, utilizing interdisciplinary expertise and evaluation outcomes. In 2010, four hospital sites had expanded PCS and eight had established new PCS. Together the 12 sites served more than 3400 patients and many of their families in the first 12 months of data collection. Nine of the 12 have evaluated financial outcomes and all have funding or commitments from their health systems to sustain the PCS in the post-grant period.

11. Heart Failure: A Strategy to Increase Palliative Care Referral

Topic: Systems Change

Description:

To improve care being given to the Heart Failure population at our facility a multidisciplinary committee was formed to review how we were meeting the guidelines for best care provided to this population and methods to improve care. Palliative care was included on this committee which offered the opportunity to increase palliative consultations for heart failure patients. The option for a palliative care consult was placed on the heart failure order set in March 2007. While this did increase the number of referrals for that population, consults to hospice and completion of Advance Directives there was still an opportunity to improve upon the process. In September 2009 the order set was changed making the palliative consultation an automatic consult with the use of the order set. Criteria also set in place to identify those patients that would be end stage: a) LVEF less than 20% or b) documentation of NYHA Class IV or AHA/ACC Stage D. Changing this consult to an automatic consult did increase referrals by 5% to this population providing an opportunity to better meet their needs for quality life. Within the next year the Heart Failure Steering committee identified an opportunity for improvement by modifying this criteria to also include patients that 3 or more multiple major co morbid conditions (CAD, OSA, HTN, Diabetes, COPD).

12. Palliative Care Consults in Patients Pursuing Curative Treatments

Topic: Systems Change

Description:

Background: The CAPC definition of palliative care (PC) includes providing care to patients irrespective of their treatment goals, including treatments with curative intent.

Aim: To share experiences of the involvement of PC in patients pursuing curative treatments.

Outcomes: Persistent physician and staff education, as well as positive patient and family feedback, has enabled the PC service at Cedars-Sinai Medical Center to be involved in care of patients pursuing curative treatments such as heart and bone marrow transplants.

We have observed that caring for these patients can be different than caring for dying patients. It can involve a higher intensity of care, with a higher observed emotional burden. We have witnessed a decrease in opioid use amongst advanced heart failure patients receiving PC. Interestingly, we have not experienced resistance from patients or families towards PC's involvement. Furthermore, potential exists to increase the productivity of PC team members and decrease staff burn out.

Conclusion: As the field of PC advances, earlier involvement with patients pursuing aggressive and curative treatments presents with new experiences and requires a rethinking of the traditional model of measuring its clinical and non-clinical impact. More studies are needed to characterize this shift.

13. Bringing Palliative Care to Rural Southwest Colorado

Topic: Small Hospitals

Description:

Poster presentation describing the startup and development of a rural program for palliative care. Program includes hospital, nursing home, assisted living, and rural home visits by the nurse practitioner. Details of quality initiatives, cost savings, and development will be presented by the nurse practitioner.

14. Improving Palliative Care in RI ICUs: A Model for Success

Topic: Systems Change, Impact Measurement

Description:

Over the past three years CHCMN's home based palliative care program, Karuna, has developed and refined a process for obtaining family feedback that includes general satisfaction, but also detailed information about interdisciplinary involvement, pain and symptom management, program logistics, and other helpful metrics that can inform efforts to improve quality. Through the use of a phone survey conducted by trained volunteers, and utilizing interpreter services, high response rates and a significant depth of feedback have been obtained. Active palliative care patient families, as well as bereaved families have been surveyed. The survey tool, a description of the phone survey process, limitations of the survey observed to date, and a report on how information gleaned from the survey process has contributed to program improvement will be discussed. Suggestions for further refinements to operationalize this survey and gain useful metrics for program improvement will be shared. The role of such a survey in SWOT and PDSA processes will also be discussed.

15. Making the Care & Communication Bundle Electric!

Topic: Intensive Care Unit

Description:

Our hospital is converting to an Electronic Health Record (EHR) in September 2011. In our current paper environment, we have had to modify forms and use stickers and labels to incorporate the care and communication bundle into our existing documentation. As a result, it has been difficult to ensure compliance and facilitate change. In addition, it has been labor intensive to manually collect and report data on these measures. As we convert to our EHR, we have been proactive in integrating the elements of the care and communication bundle into our documentation and reports for data capture. In addition, we were able to create a note template to allow our ICU physicians to easily document their family meeting note. This note template includes all of the necessary information required by CMS for the physician to bill for the family meeting. By taking a proactive approach in building portions of our EHR, we hope to accomplish two goals. One is to make it easy to document and report on the elements of the care and communication bundle. The second goal is to help pave the way for hospitals who will convert to an EHR in the future.

16. Palliative Care and SNFs: A Growing Partnership

Topic: Continuum of Care

Description:

Evergreen Palliative Care is a community based Palliative Care (PC) program under the umbrella of Evergreen Home Care Services (EHCS), which also includes Home Health, Behavioral Health and Hospice. Since 2006, the PC Licensed Clinical Social Worker (LICSW) has provided consultative decision making services in patients' residences. In late 2010, Evergreen PC was awarded a Sojourns Innovative Grant from the Regence Foundation. Our goals included adding ARNP services and focusing on building partnerships with local Skilled Nursing Facilities (SNF) to better serve SNF residents. We have created a partnership with a local SNF to provide ARNP and/or LICSW services to patients and/or families. Many of the SNF patients are recently discharged from our hospital, Evergreen Hospital Medical Center. The ARNP coordinates with our Hospital Liaison staff (funded by EHCS), and visits the SNF patient typically while they receive rehab services. The ARNP services are billable consultative symptom management and decision making services, in collaboration with the patient, family, SNF Medical Director and staff. The LICSW participates as indicated. The Palliative Care ARNP and LICSW continue to follow the patient in the community (if appropriate) in order to strengthen the continuity between hospital, SNF and home settings.

17. Palliative Care for Neuromuscular Conditions

Topic: Systems Change

Description:

In 2009 Gillette Children's Specialty Healthcare sought to expand its pediatric neuropalliative program to include more patients with neuromuscular conditions, specifically type 1 spinal muscular atrophy (SMA1) and Duchenne muscular dystrophy (DMD). The program was also expanding beyond an inpatient focus to include outpatient services. These goals coincided with the announcement in 2009 by the Muscular Dystrophy Association of a new program intended to bring attention to the ongoing palliative care needs of children with neuromuscular diseases.

Through 2009 and 2010 the palliative care team offered Gillette providers extensive outreach and education about palliative services. The neuropalliative care team provided its first consultations for SMA1 and DMD patients in 2009. Subsequently the neuropalliative medical director has participated in regular rounds with the neuromuscular team and pulmonology clinic.

The primary purposes for neuropalliative consults on patients with neuromuscular conditions are:

• To consult with families about decision making regarding care goals.

18. What Is Pediatric Neuropalliative Care?

Topic: Continuum of Care

Description:

It has been estimated that of the children referred for palliative care services in the U.S. nearly half are children with neurological, neurodegenerative, and genetic conditions. Yet despite these numbers, current pediatric palliative research focuses on caring for children with oncologic conditions.

At Gillette Children's Specialty Healthcare we have developed our neuropalliative program to help bring attention to the ongoing palliative care needs of children with neurodevelopmental impairments who might or might not be facing the end of life imminently. Our multidisciplinary team helps patients and families to focus on living, perhaps even thriving, with the child's life-limiting condition. Key elements of services provided by the neuropalliative team include:

• Assisting patients and families to negotiate the transitions between wellness and illness, and between outpatient and inpatient care.

Neuropalliative care addresses the unique needs of caring for children and families in this population across a continuum of care.

19. Life Choices: A Palliative Model Across the Continuum

Topic: Continuum of Care

Description:

Catholic Health Services is a health system which includes a full continuum of health care settings, including acute care hospitals, outpatient palliative care setting, skilled nursing facilities, dialysis settings, home health, hospice and a center for care of the developmentally disabled.

“Life Choices: A Palliative Model Across The Continuum” is a signature service that was developed within this healthcare system for patients facing serious, life threatening, chronic or progressive illness. The ultimate goal of this initiative was to provide seamless palliative care, appropriate for patients who still desire curative or life-prolonging treatments, or patients who are best served by active end-of-life management. The support and coordination of services provided by this model of healthcare has helped to ensure high quality palliative care and a timely transition to hospice care across the continuum in the acute care, long term care and hospice entities. “Life Choices” has created a unity and integration among these various care sites thus providing high quality, standardized palliative care for all patients regardless of setting within this healthcare system.

20. A Quality of Life and Communication Template for Palliative Care on the PICU

Topic: Intensive Care Unit

Description:

Children on the pediatric intensive care unit (PICU) by definition are critically ill and thus attention to their quality of life is essential. In the face of unpredictable disease trajectories, communication and decisions about proposed medical treatments must address multiple factors related to the diagnosis, treatment risks and benefits, long term effects of medical decisions, and issues pertaining to the overall prognosis. The importance of implementing palliative approaches that reduce suffering in this dynamic and emotional environment is highlighted. Toward this end, a pediatric advanced illness care coordination model was developed. Standardized early assessment within 48 hours of admission on quality of life factors for children and their families was conducted. This structured assessment included: reason for admission, physical comfort variables, socioemotional factors for all family members, spiritual well being, communication needs, and recommended integrative plan. Information from this formulated assessment has been integrated into mainstream medical care and qualitative data collected. Over 300 charts were reviewed and thematic content clustered to begin to evaluate outcomes.

A specific focus was placed on individual and family factors related to parental coping and family environment. Tailoring the delivery of medical information and communication styles in the context of this assessment will be discussed.

21. Palliative Care Results in Savings for Hospitals

Topic: Continuum of Care

Description:

PCS analyzed the utilization of health care resources for 28 patients during a period of 90 days prior to, and 90 days after referral to PCS during a five month period, excluding patients who died or transferred to hospice care during the period.

A statistically significant decrease in utilization of inpatient hospital days among the PCS patients was noted, (P<.001) and in the number of hospital admissions before and after PCS services (p<.01). (study charts will be attached)

Based on this reduction in hospital utilization in this group of patients, with savings valued at over $300,000, Palliative Care Services received a private foundation grant to work with the cancer patients treated at the Chattanooga Tumor Clinic. The $160,000 grant covers patients seen during June 2011-through May 2012 and is expected to generate hospital savings exceeding $2 million in the 12 month period.

In the future, hospitals discharging patients who re-admit within 30 days may incur the complete costs of subsequent readmissions – without the ability to bill for services. Palliative Care Services has the capability to manage complex cases within the larger Continuum of Care and will become increasingly involved across the health care delivery system.

22. Bridging The Gaps: A Cancer Center/Community Collaboration

Seniors At Home; a division of Jewish Family and Children's Services of San Francisco, the Peninsula, Marin and Sonoma Counties; San Francisco, Ca.

Team/Contact Information:

Topic: Continuum of Care

Description:

We all recognize the need for palliative care conversations and support to continue and expand beyond the hospital setting in order to achieve the best possible patient outcomes. This is a difficult task, given the general lack of funding and support for palliative care. In San Francisco, California, Seniors at Home (SAH), a division of Jewish Family and Children's Services (JFCS), a well-respected non-profit social service agency, has created a unique, community based interdisciplinary palliative care team, in the the home care setting—simply because it was the “right thing to do” in addressing palliative and end of life issues for their 200+ homecare clients. This team, under the direction of a palliative care RN, has created an informal yet powerful collaboration with the Symptom Management Service (SMS)—an outpatient palliative care co-management service in the University cancer center.

SAH provides a comprehensive range of services, including non-medical homecare, to hundreds of clients/year, many of whom have cancer and are either in treatment phase or at the end of life, with or without hospice care. The Palliative Care team of SAH provides on-going consultation, emotional, spiritual and practical support to these clients. This is a free service for anyone who is a client of JFCS /SAH. When a client is assessed as needing more in-depth palliative care from the medical perspective, they are then referred to SMS. The SMS provides outpatient palliative care consultations at the UCSF cancer center with expertise, compassion and a level of honest communication that is critical to a patient's well-being and understanding of their disease process. They, in turn, refer their patients who are in need of homecare or other support services to SAH, knowing that the palliative care conversations will be continued in the home setting. Learn how this collaboration has helped patients.

23. Closure: Changing Expectations for End-of-Life

Topic: Systems Change

Description:

The 2006 Pennsylvania End-of-Life Background Report reported dissatisfaction with pain management, social and financial burdens, availability of information, and access to palliative and hospice services for patients dying of chronic illness. To address these issues, the Jewish Healthcare Foundation launched an end-of-life initiative called Closure. Closure aims to improve care for people approaching end-of-life by changing expectations for end-of-life and sparking demand for better care. The core of Closure is the Community Conversation, which convenes community stakeholders to consider issues surrounding end-of-life care and draft a community plan to respond to these issues.

From these conversations have grown several additional components: Closure 101, an interactive, modular curriculum to enable patients and families to make educated decisions about their care; a speakers bureau equipped to take the curriculum into the community; the website Closure.org, through which participants can access the curriculum, participate in an online community and acquire tools to take action; continuing medical education to help outpatient physicians address end-of-life in their practices; and a research and quality improvement initiative to improve end-of-life care for patients with dementia in a local nursing facility. To date, Closure has connected with hundreds of individuals through face-to-face programs and several thousand online.

24. Advanced Illness Coordinated Care

Topic: Continuum of Care

Description:

To create a continuum of care for palliative care services, Kaiser Permanente (KP) implemented the outpatient Advanced Illness Coordinated Care (AICC) program. KP studied this social work intervention in collaboration with Dan Tobin, MD, Care Support of America, in a randomized control trial across three Kaiser regions. The model incorporates health counseling and care coordination matched to needs of patients with advanced illness, and delivered in cooperation with the referring physicians. The AICC components include a communication model (what we do), conceptual framework (how we do it), and six structured visits (when we do it). Key successes to implementation include enlisting leadership support, marketing the services to referring providers, starting the program in settings favorable to integration and adoption, and recruiting and training social workers with interest and expertise in palliative support. The program has resulted in improved communication about discomfort, support for decision making and problem resolution, and attention to caregiver needs. AICC also resulted in increased formulation of advance directives, and fewer inpatient admissions and ER visits, with no change in survival (Am J Manag Care. 2009; 15(11):817–825).

25. Extending Pediatric Palliative Care to Rural KS

Topic: Continuum of Care

Description:

Kansas is comprised of 105 counties, mainly rural and frontier. Pediatric hospice and palliative care (HPC) in Kansas is limited to services in metropolitan Kansas City, Topeka and Wichita, all on the eastern side of the state. Access to pediatric specific HPC does not exist in the rest of the state. Two third-year medical students in The Community Health Project, an interdisciplinary summer course offering experiences in health care settings, gained Institutional Review Board approval from KU School of Medicine to conduct oral interviews of HPC agency managers. Responses from agency managers identified 1) a desire to provide pediatric services 2) barriers to pediatric service provision, and 3) an interest in receiving pediatric training for providers via interactive televideo from the KU Kids Healing Place pediatric palliative care staff. Next steps will be to conduct a written survey of palliative care providers in the state and provide pediatric training.

26. Advanced Care Planning Team as Precursor for Palliative Care

Topic: Systems Change

Description:

An “Advanced Care Planning Team” was informally organized at a small community hospital. The goal was to ensure opportunities for patients and families to understand and implement their choices in treatment, resuscitation and palliation.

27. One Health Care System's Commitment To Providing Palliative Care across the Continuum

Topic: Continuum of Care

Description:

The Lee Memorial Health System (LMHS) is comprised of 4 acute care hospitals with 1423 licensed beds, an ambulatory surgery center, a regional cancer center, nursing homes and post acute home care services. Annually the system has roughly 70,000 hospital admissions, 200,000 emergency room visits, 10,000 trauma center visits, 40,000 surgeries, and 9300 employees. The LMHS QLife/Palliative Care program touches the lives of the patients in Southwest Florida by seeing over 4,000 new hospital consults every year. Consultations were historically done by palliative care teams in the four hospitals. Since 2010 the hospital system committed resources to allow the Palliative Care program to provide ongoing palliative care involvement post hospitalization to patients in our nursing homes, outpatient palliative care clinic and a home based palliative care nursing program. The palliative care program has continued to grow the hospital consult service (65% growth since 2008, 4000 new consults per year), developed and implemented a nursing home consult service, developed and launched an outpatient integrated palliative care clinic and has provided education and oversight to a newly developed home based nursing palliative care program. Through these efforts the health system provides palliative care across the continuum for the patients of Southwest Florida.

The non hospital programs were added through needs assessment performed through a joint effort of the palliative care team and hospital administration. Key indicators were continuity/quality of care, hospital readmission rates and in-hospital mortality rates. Patients that had involvement with the Qlife Palliative Care team in the hospital had 15 day readmission rates that were half of the LMHS 15 day readmit rate and more than half versus VHA methodology. Hospice admissions increased 39% since 2008 and hospice house admissions directly from ICU increased 108% during this same time period. The hospital also experienced an 18% decrease in discharge to death since program inception. Based on these metrics, administration felt that branching out the palliative care program would result in further improvements in patient and family satisfaction and even greater impact on cost avoidance, readmission and death statistics. The challenges have been both anticipated and surprising. We expected to face educational and culture change issues in the outpatient and nursing home settings and they were and continue to be significant. Growth, however, has been rapid in both the nursing home and outpatient sectors. Due to physician demand there is also an inpatient palliative care unit in development as well. Staffing has posed a significant challenge due to rapid growth. We have tried to maintain our staffing at 1.0 F.T.E. per 10 patients on our average daily census. Prior to the start of the outpatient, nursing home and home care initiatives we were at ten FTE's for an average daily census of approximately 110 patients. In anticipation of our growth we added a total of three 1.0 FTE's (A full time ARNP, social worker and physician) who are hired and currently being trained and oriented.

28. How We Grew an Interdisciplinary Learning Community for Palliative Medicine

Topic: Other: Culture Change

Description:

In anticipation of a Palliative Medicine Fellowship, we sought to strengthen our palliative medicine culture and support our palliative consult service by creating an interdisciplinary learning community. We invited all those interested to join us for twice monthly 90 minute sessions. During these sessions we explore one of 5 key issues related to palliative medicine: communication skills, ethics, medical content, personal awareness, and systems issues. We named this group the Palliative Medicine Scholars program or PalMS and participation includes providers from diverse specialties.

Following a relationship-centered format, members of the PalMS community select and volunteer to present on topics related to the group's interests. To date our 275 members have presented over 60 sessions across two campuses on topics ranging from palliative chemotherapy to mindfulness practices. Participants report that in addition to the content, the value of PalMS lies with strengthening relationships across caregivers in order to better work as a team and patient advocate. Implications for the field include understanding that despite diverse responsibilities, palliative medicine clinical providers share many of the same needs for clinical content, emotional support, and relationship building among colleagues.

29. Measuring the Immeasurable in Palliative Care: Patient and Family Support Card

Topic: Measuring Staff Productivity

Description:

In an effort to describe, quantify and analyze Patient and Family Support in a context understood by medical staff and hospital administration, an assessment and data gathering SUPPORT CARD was developed in March 2011. The objective has been to capture quantity and quality of care, record demographics and numbers of people seen, assess acuity and needs, track services and outcomes. The goal is to measure both staff productivity and impact.

The tool uses a medical model for needs assessment: INITIAL PSYCHOSOCIAL ASSESSMENT, PAIN/SUFFERING ACUITY SCALE (based on 0-10 pain scale) and SUPPORT DIAGNOSIS (i.e. Advanced Directive issues, Anger/discord, Isolation, Crisis, Cultural/religious concerns) in the first domain. The second domain lists SERVICE PROVIDED (i.e., Counseling, Liaison/communication, Life review, Family Meeting, Physical/comfort care) and REFERRALS. The third domain details OUTCOMES/PROGRESS (i.e. Adjusted goals of care, Improved communication, Life review facilitated, Coping strategies identified) and DISCHARGE INFORMATION. Monthly reports of productivity have been generated and submitted to the Department of Medicine and Hospital Administration. After six months of use, analysis has identified areas for programmatic and service change to enhance patient and family care and evidence-based data to support Palliative Care program growth.

Bottom line…we can report support!

30. Giving Voice to the Journey: Utilizing Oral History for Psychosocial Intervention in Pediatric Palliative Care

Topic: Other: Psychosocial Support and Legacy Building

Description:

Our PACT program brought in StoryCorps (a national oral history project) to the hospital to provide a medium for families who have a child with a serious illness to record their experiences with illness, treatment, and/or loss. The objectives of this project were 1) to allow the participants a chance to process their experiences with a significant person in their lives, 2) to provide families with a unique opportunity to share their journey with each other, 3) to validate the importance of our families and their children, and 4) to allow our families an opportunity to educate others about their experiences. The products of these sessions will provide us with 1) an opportunity to deepen our connection with our families, 2) an opportunity for legacy building that is not explicitly about making “something to leave behind”, 3) educational materials for hospital staff and community, and 4) an opportunity for our team members to continue to build meaning in their work and build on their own legacies throughout their careers. Based on survey results, the PACT team will continue to offer a similar intervention and will utilize products in our Family Resource Center and in various media throughout the hospital.

31. Decreased Hospital LOS Using IPAL-ICU and TPCT Model in ICUs

Topic: Systems Change

Description:

At the Medical Center of Central Georgia, we combined the concepts of IPAL-ICU and the Transitions and Palliative Care Therapy (TPCT) Model to drastically decrease the average hospital LOS for patients who have spent at least one day in the Surgical Trauma and Medical ICUs. The Care and Communication Bundle Sheet, addressed in the IPAL-ICU project, was implemented. Our palliative trained Transitions Counselors were given the role of insuring compliance. They also identified the Legal Next of Kin, provided psychosocial support, educated on the code statuses used at our hospital, completed the palliative screen and arranged the family meetings with all disciplines. The counselors had previously been imbedded in the ICUs, seeing about 50% of all patients. The IPAL-ICU project allowed the counselors to see 100% of the patients and gave structure to the already successful palliative intervention. We currently have six months of data showing a 2.61 day decrease in average hospital LOS in STICU and a 5.21 day decrease in MICU. This has received much positive attention from our Administration.

32. Palliative Care Outpatient Metrics: A First Look

Topic: Other: Outpatient Clinic

Description:

The Medical College of Wisconsin has had an active Palliative Outpatient clinic for many years. We have reviewed our outpatient data to better understand our service characteristics. A retrospective review of 2010 outpatient data was done. Metrics included date of referral to date of initial consult; date of consult to date of death; number of ER visits and/or hospital admissions; and reason for hospital admission post- palliative care visit. Sixty-one charts were electronically reviewed representing 37% of outpatients seen in 2010. All 61 were cancer patients. Results: Patients were seen within an average of 7 days (median=6 days). Thirty-seven (60%) were seen only once in the clinic, while 24 (40%) were seen more than once during 2010. The time from consult to death ranged from 5-504 days (Mean=125; median=83 days). Sixteen patients (26%) made 29 visits to the Emergency Department post-consult. Thirty-two patients (52%) were admitted to the hospital a total of 51 times. Reasons for hospital admission were symptom management (N=29), other medical problems (N=12), and scheduled procedures (N=10). Summary: This data provides a starting point to develop palliative care program quality improvement initiatives designed to reduce potentially avoidable ED visits and readmissions.

33. LTC to Community: Palliative Care Across the Continuum

Topic: Continuum of Care

Description:

Since its inception in 2004, the Motion Picture and Television Fund (MPTF) Palliative Care Program has taken a deliberate path of growth in order to meet the needs of the entertainment industry. It is founded on the principles of the National Quality Forum Preferred Practices for Hospice and Palliative Care and designed to serve patients across the care continuum. It was initiated in the Long Term Care (LTC) setting on our Woodland Hills campus, and later expanded to our assisted and independent-living campus residents. In 2009, the program opened to community people who receive ambulatory care in one of our greater Los Angeles health centers. The entertainment community MPTF serves is comprised of many unique people with different needs, concerns and lifestyles. Instead of molding the person to fit the model, the care and interventions we deliver are specific to the individual's needs and circumstances. Our goal is to enhance quality of life as it is identified by the person in our care. Physical and psychosocial symptoms, which interfere with the ability to take joy in the moment, are given high priority. Referrals for a Palliative Care consult are encouraged from all sources to promote timely evaluation and intervention.

34. Navigating the Rapids of Transition Management

Topic: Continuum of Care

Description:

Recognizing the challenges of Transition Management, Mount Carmel Health has developed several strategies to improve transitional care from acute care to the outpatient setting.

In this presentation we will share a brief review of:

The language and principles of effective transition management

Barriers and challenges to transition management

Strategies implemented for transition management

■ Hospital to palliative skilled care in ECF (Extended Care Facility)

Roles and responsibilities of the palliative care and hospice interdisciplinary team members

■ Communication

35. Partnering to Build a Community Hospital Palliative Care Program

Topic: Other: Program Development

Description:

Northwest Community Hospital (NCH), a 350 bed community hospital, identified both a community and patient care services need to establish a palliative care program. Located in the Northwest Suburbs of Chicago, NCH is centered in a community where 20% of the population is over the age of 65 and numerous nursing homes are in the hospital service area. With 53% of our inpatients are over the age of 65. Establishing a program to help manage the chronic critical illness of patients became a priority in the NCH Community.

NCH evaluated the feasibility of developing a program internally or developing a partnership with an established Palliative Care Program in the regional area. After extensive research and an attempt to establish an internal program the decision was made to partner with Midwest Palliative Care and Hospice CareCenter. Midwest is a Palliative Care Program that has been established in the Chicagoland area and is noted nationally for their leadership in Palliative Care. The partnership was formalized 18 months ago. The implementation took place over 4 months.

The benefits of the partnership were quickly evident:

• expert resources available to develop program and educate staff

Outcomes after 18 months (some not all) include:

• rapid launch of a quality Palliative Care Program

Integration Strategies used:

Medical Director on site, established team integrated into hospital and committees

• Joint Integration Committees established to include:

Summary: Partnership with an established Palliative Care Program is an effective business model for implementing a palliative care program in a community hospital. Integration of the program partners into the community hospital culture is key to ensure success of the program. Development of shared strategic plan and vision key to move forward the program to success and future growth.

36. Evaluation of Palliative Care Initiatives in the Intensive Care Setting

Topic: Intensive Care Unit

Description:

Problem: Critical care staff is often morally distressed and frustrated by the end-of-life experience of patients while families are frequently dissatisfied with the palliative care provided.

Project Design: A three phase approach was undertaken to assess satisfaction of palliative care for physicians, medical students, nursing staff and families. Survey methods were designed to assess patient/family, physician, and nurse satisfaction of palliative care service initiatives.

Patient and Family Satisfaction: The Ochsner Palliative Care Committee consulted with Press Ganey to develop a bereavement survey to assess family satisfaction with end of life care. The 40-question bereavement survey was produced with sections including: Time of Death, Visitors and Family, Physician, Nursing, Personal Issues, and Room. A Pre- palliative care consult service survey was conducted with baseline data retrieved between December 2005 and March 2006. Palliative care consultation services were then initiated. Post survey overall and unit based data has been collected since that time.

Physician Training Satisfaction: A survey was developed and administered to residents at the beginning and end of their rotation on critical care service to evaluate satisfaction and confidence with new palliative care educational initiatives. Case-based approach educational initiatives were utilized to foster resident confidence in delivering bad news, discussing poor prognosis, explaining the dying process, and providing palliative care within the medical intensive care unit.

Palliative Care concepts were taught via scheduled didactics, expert role modeling, hands-on care of dying patients, and mandatory participation, organizing and providing family conferences. Resident case-based discussion of specific patients was implemented as a debriefing for difficult end of life cases each month. Led by a critical care staff physician, palliative care medical director and palliative care APRN, these sessions provide a framework to reinforce the confidence of young physicians. Open-ended questions are employed to stimulate resident reflection on their decisions and to guide the discussion to reinforce palliative care principals'.

Nursing Satisfaction: Palliative Care APRN and critical care nursing developed and implemented a standardized order set for planned withdrawal of life support. A pre and post implementation survey was developed and utilized to evaluate nurses' perceptions of withdrawal of life support with and without the order set.

Results

• Phase I Patient and Family Satisfaction: ICU survey ongoing improvement is demonstrated from a 2006 baseline of 78.0% to 1^st qtr 2011 score of 94.7%. The institutional 2006 pre-Palliative Care score was 76.7%. Ongoing improvement seen 2007-2011 with 1^st qtr 2011 score of 95.2%. ICU now uses bereavement survey as primary instrument in patient satisfaction quality improvement initiatives. Dying process sensitivity tools, bereavement trays, resource booklets, and other improvements were developed

Conclusion: All-around satisfaction of palliative care in ICU settings can be measured and improved.

37. Implementation of a Palliative Care Program for the Largest Health Care System in Oregon

Topic: Continuum of Care

Description:

Providence Health and Services (PH&S) is an integrated health care system with 27 hospitals serving 5 West Coast states. In 2010 this catholic health care system committed to make palliative care available to anyone served by any of its ministries.

This is the first year's report on the challenges and successes from the implementation of this palliative care strategic plan in one part of PH&S, the Oregon Region. The Oregon ministries include 8 hospitals (ranging from 25 to 523 beds), long term care facilities, a PACE program, a 700+ physician practice with 47 Clinics, a home services agency (comprised of a home health agency, a home hospice, a specialty pharmacy, and a durable medical equipment agency), and a large health care insurance plan. The Oregon Region of PH&S has incentivized its leadership and management teams to deliver on the 13 minimum specifications established by the PH&S board.

This report will outline the minimum specifications, explain how targets and measurements have been established, describe the networking put in place to achieve the targets, and show the progress to date. The tools and materials created in this process will be presented.

38. Improving Interpreting in Palliative Care

Topic: Education and Marketing

Description:

Although studies suggest that using professional health care interpreters improves care quality and satisfaction for patients with limited English proficiency, significant communication errors may still occur during crucial discussions between language-discordant patients and providers. One potential explanation for the observed high rates of communication errors may be that health care interpreters lack appropriate training in end-of-life care.

We developed an innovative training program, Interpreting in Palliative Care, to prepare health care interpreters for the linguistic, cultural, and personal challenges of interpreting for palliative and end-of-life (EOL) discussions. The core elements of the eight-hour in-person/online training program include: (1) a conceptual introduction to palliative care; (2) three videos of EOL interpreter-mediated encounters modeling best practices in palliative care interpreting; (3) an introduction to palliative care vocabulary terms and exercises enabling practice interpreting from English to seven other languages, and (4) exercises on managing the emotional impact of interpreting EOL conversations. Pre- and post-testing of pilot group participants demonstrated that the curriculum was effective in improving interpreter understanding of palliative care, as well as the specific techniques and vocabulary used to interpret these conversations. We will incorporate lessons learned from the pilot group to revise and disseminate the curriculum nationally.

39. Successful ICU Family Meetings

Topic: Intensive Care Unit

Description:

Shore Memorial Hospital instituted a program of family meetings facilitated by a Palliative Care RN for all ICU patients. A review of six months of family meetings has demonstrated an avenue for adoption of the Palliative Care philosophy in the ICU. One of the challenges to previous multidisciplinary family meetings was unavailability of physicians during daytime hours. The RN facilitator was able to gain physician “buy-in” to initiate discussions with the patient and family prior to any Palliative Care consult. Topics discussed regarded the presence of an advanced directive, how the intent of an advanced directive should be reflected in the individual's code status, as well as pain management, dyspnea management, prognosis and goals. The facilitator leads the multidisciplinary meeting and reports back to the attending physician the findings of the meeting, making recommendations for Palliative Care consults when appropriate. The family meeting program was able to demonstrate an overall increase in Palliative Care consults hospital wide by 69%, decrease the number of days between admission to the ICU and a Palliative Care consult, and often reflect a decrease in the daily charges on patients who received a Palliative Care consult.

40. Bereavement Guide Meets Family Needs Hospital Wide

Topic: Systems Change

Description:

Each year approximately 50% of our palliative care patients pass away and many of their family members are overwhelmed with grief. Helping them through the process of bereavement is a vital component of palliative care. The development of Journey: A Bereavement Resource Guide helps answer important questions for families experiencing anticipatory grief and provides ongoing support throughout bereavement.

The goal was to create a clearly written, informative and above all empowering resource for families. The guide begins with an expression of sympathy and answers the question “What is grief?” It provides resources for bereavement services; websites, a reading list, and alternatives such as music, yoga, relaxation and meditation. The creation of the guide began with the involvement of a patient's daughter. Her experience with grief and the experiences of many other family members' impacted research, selection of images, and text.

The guide, highlighted during presentations, helped clinicians and hospital administrators appreciate that not only can palliative care be initiated at time of diagnosis and provided through treatment or cure; it can also extend into bereavement. Well received, the guide is being used hospital wide to support families in need as they embark on their journey through the bereavement process.

41. Life Sustaining Management and Alternatives (LSMA) Program: A Palliative Care Construct in an Urban Emergency Department Setting

Topics: Emergency Department; Impact Measurement

Description:

An IRB exempt review of 131 charts was conducted on patients seen the emergency department who received palliative consultation by a dedicated ED palliative care team. Data was gathered and stratified into several categories to evaluate program effectiveness. Quality indicators extracted from the study focused on: formulation of patient code status in the emergency department, number of patients who were discharged home on home hospice with arrangements made from the ED, number of patients who were transitioned to inpatient hospice from the emergency department, number of patients referred to inpatient palliative care for follow-up. Additional areas included the impact consultative services had on patient average length of stay with respect to patients' level of care intensity. Also, the number of intensive care admissions as well as, hospital admissions that were circumvented when comfort care was chosen as the plan of care. Overall, high-intensity ICU admission ALOS was considerably less yet, intermediate-intensity and medical/surgical level of care days was slightly higher in the study group. Findings also revealed that 21% to 36% of patients admitted to med/surgical units along with 13% to 31% of patients discharged from the ED met higher intensity admission criteria according to InterQual 2011 guidelines.

42. StoryCorps Legacy: Recording Stories of People with Serious Illness

Topic: Life Review/Reminiscence

Description:

StoryCorps, a national oral documentary project with an archive of more than 40,000 interviews at the Library of Congress and weekly broadcasts on NPR's Morning Edition, has built upon existing services to create, implement, and evaluate a new model of therapeutic listening and reminiscence for people with serious illness and their families. Through StoryCorps Legacy, palliative care organizations are provided with state-of-the art recording equipment and are trained to record reminiscence interviews with the people they serve. The mission of the project is to record, preserve, and share the stories of this community. Informed largely by the StoryCorps Memory Loss Initiative – a program that has collaborated with more than 180 organizations serving aging populations and people with Alzheimer's disease and traumatic brain injury, StoryCorps Legacy complements the mission of palliative care organizations by offering a service that can be embedded within providers' ongoing programming. During its pilot year, Legacy partnered with six local and national organizations to record nearly 100 interviews. Now in Year One of the project, Legacy stories continue to be recorded, bringing participants closer together and enhancing the services of palliative care, hospice, and disease-specific organizations.

43. Spiritual Care Advance Directive (SCAD): A Guide For a Spiritual Counselor to Provide Therapeutic and Creative Interventions at End-of-Life Care

Topic: Continuum of Care

Description:

Families and healthcare professionals recognize the importance of identifying and communicating spiritual wishes, along with the need to provide supportive knowledge and affirmation. This helps an individual find comfort, strength, and meaning-reconstruction. Herein lays the lack of a standardized approach to help individuals with life-limiting illnesses to speak for themselves who are seeking meaning of death to relay their spiritual beliefs and wishes.

The Spiritual Care Advance Directive (SCAD) will empower the healthcare professionals to integrate the bio-psycho-social-spiritual history. Standardizing the SCAD for use as a spirituality-based tool will improve quality of life (QOL) by addressing spiritual needs along the illness trajectory.

There are 6 questions pertaining to which address the mind and spirit dimension. The next 8 questions are to help increase awareness of one's end-of-life (EOL) needs and find ways to say “good-bye” in accordance with own spiritual beliefs, communicating that the individual is not giving up on life but is “letting go,” to yield to his or her spiritual plans of care (SPOC).

With its brevity and ability to integrate key of EOL issues, the SCAD which is sensitive to multi-culture-faith, will be perceived as a loving gift out of existential humanity and a compassionate caring soul.

44. Inpatient Palliative Care: A Review of Current Evidence

Topic: Education and Marketing

Description:

Early implementation of specialized palliative care delivered in outpatient settings improved quality of life and mood of patients with advanced cancer. Despite rapid growth of specialized inpatient palliative care, much of the emerging evidence specific to hospital-based efforts is descriptive in nature, or methodologically flawed and heterogeneous in overall design. In an effort to create a comprehensive picture of the current state of hospital palliative care, the purpose of this review is to present recently published evidence unique to two primary models of hospital-based palliative care: palliative care consultation teams and traditional palliative care. PubMed and CINAHL were searched for research evidence related to inpatient specialized palliative care interventions published in the last five years (2006 to 2011). Randomized controlled trials (1), observational studies with comparison/control groups (15) and observational studies without comparison/control groups (21) are reviewed. Patient and family outcomes, length of stay, discharge disposition and costs associated were examined. Future expansion of inpatient palliative care into pediatric and emergency care areas is also addressed. Increased awareness of the movement towards palliative care in U.S. hospitals will eventually foster high quality studies such as the Randomized Controlled Trials conducted in the outpatient realm.

45. Improving Home Hospice Transitions with a Family Checklist

Topic: Continuum of Care

Description:

Providing safe transitions between healthcare settings is a core focus in palliative medicine. In the development of a new inpatient palliative consult service we have seen where the hospital's existing discharge process, though usually adequate for regular home discharges, has failed to provide an appropriate transition to the home hospice setting.

Our team has developed a system to supplement the current discharge process without adding responsibilities to our already overburdened nurses. Our supplemental discharge system highlights enhanced communication and a written discharge checklist to be completed by a family member of the patient before leaving the hospital. Our consult team provides enhanced communication with the patient and families by giving access to the team's 24/7 pager and assigning a family member to complete the checklist on day of discharge after discussing each item on the checklist and its importance. We also contact the accepting hospice agency to discuss each patient, ensure continuity, and reinforce team availability. We plan to evaluate the success of the supplemental system with follow-up calls to families and hospice nurses post-discharge. Roles and duties for team members will be discussed. Feedback, discharge complications (re-hospitalization, uncontrolled symptoms, lost follow-up), and modifications to our protocol will be reported.

46. Creating a Viable Hospital Policy for Discharge of the Terminally Ill, Intubated ICU Patients with Comfort Measures, and Removal of Life Support in the Home: Yes, We Can

Topic: Intensive Care Unit

Description:

When this hospital's palliative care department asked the question, “could a terminally ill, intubated ICU patient be transferred home and extubated with comfort measures in the home”, there was scant literature to provide guidance. With the assistance of a multidisciplinary team, solutions were sought, a policy was written and new practice was implemented.

Review is provided of the process to bring about this extraordinary plan of care, the steps to have a seamless transition and the lessons learned along the way. The support of the health system's partners and from the community has created a viable, working model for others to examine and implement for their own community needs.

The answer to the question is, “Yes, it is possible to transfer an intubated, terminally ill patient home safely and effectively.” This presentation provides insight into how one hospital effectively created a policy to provide this care.

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