Abstract
The topic areas for abstract submission include:
• Hospital-Based Palliative Care: Models of Care, Finances, or Staffing • Pediatric Palliative Care Programs • Clinic-based Palliative Care Programs • Home-visit Palliative Care Programs • Long-term Care Palliative Care Programs • Intensive Care Unit–Palliative Care Integration • Emergency Department–Palliative Care Integration • Accountable Care or Patient-centered Medical Home Palliative Care Models/Outcomes • Reducing Hospital Readmissions or Inpatient Mortality • Data Demonstrating Palliative Care Impact on Clinical Outcomes, Family or Provider Satisfaction • Joint Commission Palliative Care Certification • Improving Generalist Palliative Care • EMR/Documentation • Telemedicine Palliative Care Programs • Creative Solutions to a Common Program Problem • Other
1. Team-based Supportive Care Approach Late in Life: An Ongoing Relationship Provided by a Nonclinical Care Guide and Clinical Team Supporting the Medical and Nonmedical Needs of Patients, Families, and Caregivers. Will the Addition of a Nonclinical Member to the “Hospice Type” Interdisciplinary Team Support Individuals Late in Life?
Allina Health Division of Applied Research Allina Commons
Minneapolis, MN 55407
Sandra E. Schellinger, NP
Clinical Co-Investigator
Allina Health
2925 Chicago Ave. So.
Minneapolis, MN 55407
612-262-1444
Dr. Eric Anderson, Principle Investigator
Dr. Heather Britt, PhD, Research Co-Investigator
Kim Radel, Director of Operations
• They are often at a loss when seeking support within the U.S. health care system.
• Those who receive services enter a profoundly fragmented system where coordinating and navigating is often overwhelming.
• Clinicians lack standardized, reliable systems to integrate late-life supportive care services into primary care and other settings.
1. Between 2013 and 2014, 350 to 500 heart failure, dementia, or stage 3 or 4 cancer patients will be enrolled in the study.
2. Individuals will be selected through an electronic medical record report and live within a 25-mile radius of our tertiary medical setting and primarily live outside of long-term care.
• Reliably address patients' and families' wishes and goals and needs of the whole person,
• Improve overall quality of life for patients and families,
• Improve the care experience of individuals and their families,
• Lower total costs of care as shared decision making leads to more informed care decisions,
• Improve utilization of hospice while avoiding undesired hospital admissions, and
• Improve job satisfaction of doctors, nurses, and other team members.
Whole person care is tended to by:
• Hearing the story of the individual through their eyes as it unfolds,
• Individualizing care in accordance with wishes and goals,
• Creating and integrating an individualized plan across settings,
• Partnering with patients to share ownership and responsibility for navigating illness and facilitating wellness,
• Communicating and coordinating goals and wishes across settings,
• Supporting self-care through shared decision making, tools, and additional resources, and
• Promoting societal acceptance by raising awareness and normalizing conversations around serious illness.
Care Guide: Two years of post-secondary education, experience in loss or caregiving, and good communication skills.
Clinicians: Expected professional training and palliative care experience.
• Healing Presence and Narrative Interviewing
• Shared Decision Making or Advance Care Planning
• Coordination
• Team Dynamics
• Cultural Understanding
• Critical Thinking and Clinical Judgment
• Process Improvement/Systems thinking
• The nonclinical care guide establishes an ongoing, personal relationship to hear the life story and understand goals of living.
• The team supporting the care guide helps to maintain focus on the whole person.
• Clinical experts from the team advise the care guide and participate in regular team conferences providing direct care to participants on an occasional basis.
• The care guide partners with patients and caregivers to get the right support from within the health system, their community, and family's own strengths and assets.
• The primary provider is kept in the circle of communication including participant and family goals and values.
Initial results and feedback are beginning to show that the presence of a care guide and clinical team as the primary contact for a long-term relationship allows patients and families to be heard, listened to, and feel supported, allowing them to be more engaged and activated with their care experience.
2. Reducing Readmissions and the Measurable Impact of PCC
Allina Health Hospice and Palliative Care
St. Paul, MN 55114
Laura Lathrop, DNP, ACHPN
Palliative Inpatient Service Clinical Lead
United Hospital Palliative Care Consult Service, part of Allina Health
1055 Westgate Drive, Suite 100
St. Paul, MN 55114
952-250-4344
Drew Gottfried, DO, Hospitalist
Karen Tomes, Dr. of Care Management
Amir Davy, Data Analyst
As health care systems prepare for the impact of the first initiative of the Patient Protection and Affordable Care Act (PPACA), which is to reduce potentially preventable readmissions (PPR), the relevance of palliative care's (PC) role has been questioned (retrieved August 6, 2013 from: www.cms.gov/Research-Statistics-Data-and-Systems/Research/HealthCareFinancingReview/downloads/08FallPg75.pdf). In the Allina Health system in 2012, one hospital's 30-day readmission rate for those persons seen by the PC consult (PCC) service was 15.7% compared with 6.5% for those not seen by PC. Readmissions are burdensome for persons and their families and emphasize the most dysfunctional part of the health care system. Improving performance in readmissions addresses the “triple aim”: patient satisfaction, higher quality, and lower cost of care. Unsatisfactory performance by hospitals beginning in 2013 will result in a penalty by Medicare of 1% payment cuts the first year with escalation to 3% by the third year (retrieved on July 30, 2013 from: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html).
• Identification of a “new” at-risk population appropriate for PC consults earlier in their disease trajectory using key criteria and
• Focus on the consult process and key performance markers that improve identification of discharge goals of care.
The criteria used included common factors identified in the population of PCCs done after the first admission or a PPR during the previous year.
During the pilot we were able to reduce the PPR to 8.3%. This was an improvement from our expected rate of 15.7% and continued into the first quarter of 2013 with a PPR of 6.2%. The key performance metrics used were symptom control, follow-up visits including a family meeting with discussion about prognosis and establishment of goals of care, and documentation of that discussion on Provider Orders for Life Sustaining Treatment (POLST) prior to discharge. The 3M™ Health Information Systems Potentially Preventable Readmissions Classification System was utilized. This 3M methodology identified PPRs within 30 days by determining clinical relationships (retrieved July 30, 2013 from: http://solutions.3m.com/wps/portal/3M/en_US/Health-Information-Systems/HIS/Products-and-Services/Products-List-A-Z/PPR-and-PPC-Grouping-Software).
3. Pediatric Palliative Care Program Development
Batson Children's Hospital University of Mississippi Medical Center
Jackson, MS 39110
W. Richard Boyte, MD, MA
Director, Pediatric Palliative Care
Batson Children's Hospital
2500 North State Street
Jackson, MS 39110
601-984-2940
Jodee Newell, RN, MSN, ACNP-AC
Charles Christian Paine, MD
Only 20% of Mississippi hospitals have access to palliative care (CAPC Report Card 2011). At the state's only academic health care center, the University of Mississippi Medical Center, no palliative care program existed prior to July 2009 when the pediatric palliative care program was established at Batson Children's Hospital. An inpatient consultation service for pain and symptom management was established as well as an outpatient clinic and primary inpatient service for management of serious illness and chronic complex conditions. Perinatal bereavement counseling was also later established. Major referral services have been hospitalists, oncology, neurology, neurosurgery, surgery, and critical care. An area identified for collaboration involved the transitional care of children who remain seriously ill and in medically fragile condition following critical illness. The palliative care team oversees preparation of family members for care of these children in their homes. The long-term management of ventilator-dependent children who reside in the hospital or in their homes became the responsibility of the palliative care service. Recently, 10 beds in an existing unit were designated for palliative care. Under the palliative care umbrella, four main categories of service now exist:
• Pain and symptom management
• Chronic complex illness/condition management and care coordination
• End-of-life care/hospice care
• Home ventilator management
General consultation/admission criteria (derived from recommendations from the Center to Advance Palliative Care) are presence of an acute serious illness or chronic, complex illness/condition AND one or more of the following:
• Two or more hospitalizations within 6 months
• Difficult pain or symptom management
• Patient, family, or physician uncertainty regarding prognosis
• DNR order or ethical conflicts
• Need for complex care coordination
• Prolonged hospitalization of greater than 3 weeks
• End-of-life care
In order to improve the understanding of the scope of services and to increase consultations and referrals the following are being developed:
• Consultation triggers
• Palliative care scoring system for consultation
• Further education of faculty and staff
It has been suggested by hospital leadership that a service by consultation only would be more financially favorable. We have made an argument to continue our primary inpatient service due to the following proposed benefits:
• Maintenance of a medical home for infants, children, and adolescents with chronic complex conditions
• Improved family support and satisfaction
• Cost savings
• Cost avoidance
• Length-of-stay reduction
• Improved quality of life
• Improved overall quality of care
• Improved length of survival
Inpatient care of new patients is often initiated by consultation. Patients can be transferred to the palliative care service if desired by the consulting physician. Outpatient services are largely limited to ongoing care of patients seen initially as inpatients. Third- and fourth-year medical students can perform clinical rotations with the palliative care team. Pediatric residents gain first-hand experience in palliative care also. An effort to establish ACGME accreditation for a hospice and palliative medicine fellowship is underway. Advanced certification in palliative care by the Joint Commission is being pursued. A grant for funding this effort has been obtained from the LIVESTRONG Foundation through its Community Impact Project. The lack of palliative care access in our state has created an unexpected advantage. The absence of prior experience has allowed an opportunity to introduce the benefits of palliative care without many preconceptions. Success of the pediatric palliative care program has created interest for an adult palliative care program at our center.
4. Using Available Data to Look at Palliative Care Impact on Readmissions
Baystate Medical Center
Springfield, MA 01199
Diane Dietzen
Medical Director Palliative Care
Baystate Medical Center
749 Chestnut St
Springfield, MA 01199
413-794-1017
Adrienne Seiler, MD
Carlo Ronca
Palliative care services have been shown to reduce overall cost of services, improve hospice referral and length of stay (LOS), and improve use of advanced illness care or other intensive home services. As part of an effort to expand impact measures into other areas of importance to medical centers, we have begun to look at readmission data. Poor communication and lack of advance care planning are recognized as frequent factors in the analysis of readmissions, and may be impacted by palliative care interventions during an admission. At Baystate Medical Center, we are able to track readmission events, and timing, for patients who have been seen by the inpatient palliative care service. In the first year of the new palliative care service, we looked at data about numbers of readmissions and sites of discharge, and also cost data for the admissions. Our readmission rate was 26.5% over a 10-month period. The data showed these patients have frequently been admitted prior to the index palliative care admission also. Our new efforts are to investigate how to create appropriate comparison groups, in order to look at rates of readmission for patients seen by the palliative care service, and patients not seen. We are using severity scores, which are already calculated for individual patients, and reported within the hospital, as well as other data reported for quality measurement purposes, that can be used to compare groups of like severity. Measures being used include initial encounter severity of illness score and initial encounter risk of mortality score, as these are reported in the Premier database. We will also look at other data collected, to begin to determine whether we can create composite measures to include number of prior admissions, DRGs, and site of discharge that can help us to look at similar patient populations with and without palliative care consultation. Patients admitted to hospice after their index telemetry care admission will need to be excluded from these data. Patients who were readmitted to observation status may need to be analyzed separately also. We will report our data for our group of over 700 patients seen by the palliative care service, and a comparison group, looking at these methods of adjusting for severity. Creating strategies that allow available data to help create comparison populations can create opportunity for other palliative care programs to demonstrate impacts on readmission. Readmission data will be important measures for both hospitals and accountable care organizations.
5. Frailty and Urgent Surgeries: Improving Outcomes
Baystate Medical Center
749 Chestnut Street
Springfield, MA 01103
Dr. Pradeep Kumbham
Research Associate
Baystate Medical Center
280 Chestnut Street
Springfield, MA 01103
413-209-4135
Dr. Mihaela Stefan
Dr. Peter Lindenauer
Dr. Maura Brennan
Diane Dietzen
6. Collaboration to Promote and Enhance Community-Based PC
California HealthCare Foundation
Oakland, CA
Kate O'Malley
Senior Program Officer
California HealthCare Foundation
1438 Webster Street, #400
Oakland, CA 94612
510-587-3181
Kathleen Kerr
Brian Cassel
Kate Meyers
• Palliative care clinics (embedded in specialty or primary care practices; co-located in specialty or primary care practices; and stand-alone),
• Home-based palliative care services,
• Distance/telephonic palliative care services, and
• Other services (i.e., advance care planning programs) to support patients with advanced illness and their families.
Through the PCAC, palliative care clinical and administrative leaders interact either in-person or virtually in collaborative learning sessions, structured around clinical models, operational issues, implementation strategies, financing approaches, and methods for assessing quality and utilization impacts. Participants share their experiences, practices, and challenges related to all aspects of running their CBPC services, such as staffing, interdisciplinary team dynamics, education, enrollment and discharge criteria, communication with referring providers, and improving transitions between CPBC and other services across the care continuum. Smaller topic-based interest groups address the role of palliative care in accountable care organizations, educational strategies to increase “primary” palliative care competencies, and clinical documentation practices. Based on PCAC team leaders' expressed need for and interest in quantifying the utilization and fiscal impacts of their CBPC services, CHCF provides interested PCAC teams with technical assistance and other resources to address their measurement goals. This work helps teams develop a strong business case for their services, and identify and prioritize opportunities for expansion. The three components of the PCAC metrics program are:
• Utilization Analysis: PCAC sites receive the tools and resources needed to analyze end-of-life utilization patterns for patients with chronic, life-limiting illnesses, to identify opportunities and document impact for their CBPC services;
• Staffing and Volume Data: PCAC sites receive data describing staffing and caseload for the different types of CBPC services offered by PCAC members;
• Supportive Care Calculator: PCAC sites have access to an interactive tool that uses data describing service volume, staffing, and utilization/financial impacts to generate return on investment (ROI) estimates and actual ROI results.
7. One Organization's Journey to Become “Conversation Ready”: The “Conversation Nurse”—an Integral Component to Partnering with Patients and Their Families in the Goals of Care Conversation
Care New England
Warwick, RI
Nancy Roberts, RN
CEO
401-737-6050
Kate Lally, MD, FACP (
Ruth Scott, RN
Michelle Pattie, RN
Kelly Baxter, CNP
Care New England Health System joined the IHI-sponsored Conversation Project as a “Pioneer Sponsor” in late 2012. This partnership required a system-wide commitment to be “Conversation Ready” within one year, recognizing that a major cultural change would be necessary to reach this ambitious goal. The “Conversation Nurse” role was conceived as a way to engage patients and their families in discussions about what matters most to them, focusing on their goals, wishes, and desires. The Conversation Nurse is a hospice-trained, registered nurse who is integrated into the Palliative Care team, and visits patients at the request of another team member or the attending physician. The facilitated conversations with patients and their families may be done independently by the Conversation Nurse or in conjunction with the physician. Questions such as “What is important to you?” and “Where do you want to receive care, at home or in the hospital?” are asked, while a frank and open dialogue about resuscitation and life-sustaining treatment is also an essential component of the discussions.
Typically, the family meetings are time intensive and require a highly skilled and sensitive communicator. The Conversation Nurse, who is dedicated to this function, does not face the same time demands as other team members. When the meetings occur with only the Conversation Nurse, she/he communicates the wishes of the patient and family to the primary team so these desires are integrated into the plan of care. More often than not, multiple conversations are needed to ensure full understanding and clarification of the patient's and family's wishes. The availability of a dedicated Conversation Nurse allows for this and has enhanced the quality of family meetings and the number of patients served.
The Conversation Nurse model has proved to be cost-effective; it allows the medical team to dedicate its time to additional palliative care consultations and symptom management with a secondary benefit of a growing hospice census. Future plans include expanding the Conversation Nurse model to local Patient-centered Medical Home practices, area skilled nursing facilities, and the home health program.
8. Persons at High Risk for 30-Day Mortality from Pneumonia
Catholic Health System
Buffalo, NY
Bruce Naughton, MD
SUNY/Buffalo; Catholic Health System
55 Melroy Avenue
Lackawanna, NY 14218
716-819-5050
Nikhil Satchidanand
Linda Horton
Penny Tirpak
Angela Wisniewski
Brian D'arcy
9. Accurate Assessment of Cost Savings with Early Involvement of Palliative Care
Cedars-Sinai Medical Center
Los Angeles, CA
Parag Bharadwaj
Chief, Palliative Care Medicine
Sentara Healthcare
835 Glenrock Rd
Norfolk, VA 23502
714-330-7301
Andrew Shubov
Rishi N. Gupta
Ishita Sharma
Lynn H Spragens
10. Palliative Care Consults and 30-day Readmissions
Cooper University Hospital
Camden, NJ
Mark Angelo, MD, FACP
Division Chief, Palliative Medicine
Cooper University Health Care
3 Cooper Plaza, Ste. 506
Camden, NJ 08103
856-968-7003
Barbara Sproge, MSN, CHPN
This is a retrospective chart review that examines 30-day hospital readmission rates for patients admitted to medical, oncology, or critical care services. We chose to review conditions specific to palliative care in order to determine the impact of a palliative care consultation on 30-day readmissions. We reviewed all patients with a primary diagnosis of lung cancer, lung metastasis, pancreatic cancer, gastrointestinal metastasis, and bone metastasis. In all of the reviewed diagnoses, those who received a palliative care consultation were less likely to be readmitted within a 30 day period. All patients seen by the palliative care service at our institution receive a multifaceted approach to care. Primarily, these patients are given expert pain and symptom management through our palliative care interdisciplinary team. In addition, patients' goals of care are addressed with the interdisciplinary team in conjunction with the primary service and patient and family/caregivers. We believe that the ability to provide expert control of symptoms and to direct patients toward their proper and desired goals are the interventions made by our palliative care team that brought about fewer 30-day readmissions. We believe these data should serve as an impetus to review patients seen by a palliative care program during hospitalization to support and sustain the mission of the palliative care hospital-based inpatient consultation service. When presented to those who would be considered stakeholders for palliative care within an institution, this should bring forth a compelling argument for the benefit of palliative care from a clinical and fiscal standpoint. In the future, these data should be supported by a prospective, randomized trial that considers palliative care consultations as an intervention for reduction in 30-day hospital readmissions.
11. Caring About Residents' Experiences and Symptoms (C.A.R.E.S.) Program—Providing Palliative Medicine to Nursing Home Residents
Eastern Virginia Medical School/Sentara Lifecare
Norfolk, VA
Deborah Morris, MD
Assistant Professor of Medicine
Eastern Virginia Medical School
825 Fairfax Avenue
Norfolk, VA 23507
757-466-7040
Marissa Galicia-Castillo, MD
Kim Chafee, M Div
Nursing home residents have limited access to palliative medicine services, especially to address goals of care and management of pain and other symptoms related to complex medical conditions that many of these residents face. Sentara Life Care and the palliative medicine section of the Glennan Center for Geriatrics and Gerontology at EVMS, an independent medical school, have partnered to develop a program to bring these much needed services to long-term residents. The C.A.R.E.S. Program was developed as a collaborative venture to provide nursing home residents resources for effective palliative medicine care. Nursing home residents are a vulnerable population who often face serious medical illnesses resulting in untreated pain and other distressing symptoms. This population has specific needs from both the patient and facility level, including advance care planning, tailoring decisions to specific patient goals and preferences, and providing adequate pain and symptom management. Palliative care medicine providers are trained in these areas. The integration of palliative care medicine resources into standard nursing home practice has been suggested but has not been done in most communities. The C.A.R.E.S. program seeks to improve symptom management, communication with residents, family, and staff, improve satisfaction with care, and reduce hospitalizations and procedures that are incongruent with residents' personal values and goals of care. The C.A.R.E.S program began in November 2012 with the initiation of knowledge and attitudinal surveys as well as educational modules on palliative medicine principles for the staff of Sentara Newtown, a 197-bed facility, one of Sentara Life Care's flagship long-term care programs. A palliative medicine service was started in January 2013 to provide expert consultation by palliative medicine physicians and chaplaincy. Patients are identified by a team-based approach during interdisciplinary care plans involving nursing, social work, nurse practitioners, and physicians. Palliative medicine faculty members spend 3 half-days rounding on residents in consultation. These rounds include expert recommendations as well as one-on-one education of staff as well as providers. Concepts are communicated on several levels with attending providers, via individual discussions and communications via medical record notes and e-mail. Mandatory nursing and staff education is presented through face-to-face (synchronous) education as well as through the asynchronous web-based learning. In the initial surveys of 60 staff members, we have found that there is a dearth of palliative medicine knowledge at the Sentara Newtown facility. There is, however, an enthusiasm for learning more, to help provide their residents with the best care possible. New experiences and lessons learned from the collaboration include the inclusion of skilled nursing facility patients as well as the long-term care population, as we find that these patients often have been in and out of hospitals without truly addressing goals of care. A major goal is the development of a portable program that can be transported to other facilities. Measurements used for evaluation of the innovative partnership will be a follow-up survey on comfort with palliative medicine concepts (both knowledge and attitudes) for staff as well as the number of referrals to hospice services, which have been traditionally underutilized in the long-term care setting. Currently, 48 patients have benefited from the program. We are also tracking symptom prevalence, hospice use, hospitalizations, and emergency room visits among these residents.
12. Should Direct ICU Discharges Trigger a PM Consult?
Geisinger Medical Center, Geisinger Health System
Danville, PA
Andrew Espenlaub, DO
Fellow, Palliative Medicine
Geisinger Medical Center
100 North Academy Avenue
Danville, PA 17822-1342
570-271-7383
Andrew Espenlaub, DO
Carlos Fernandez, MD
Zankhana Mehta, MD
Neil Ellison, MD
13. Novel Approaches to Increase PMP Consults
Geisinger Medical Center, Geisinger Health System
Danville, PA
Carlos Fernandez, MD
Fellow, Palliative Medicine Program
Geisinger Medical Center
100 N. Academy Ave
Danville, PA 17822-1342
570-271-7383
Carlos Fernandez, MD
Andrew Espenlaub, DO
Neil Ellison, MD
Zankhana Mehta, MD
14. Palliative Care Curriculum in a Community Hospital
Greenwich Hospital
Greenwich, CT
Donna E. Coletti, MD, MS
Medical Director Palliative Care
Greenwich Hospital
5 Perryridge Road, Suite 3-2110
Greenwich, CT 06830
203-863-4622
Felicia Hui, MD
A summary of the strategy and implementation of an educational curriculum inclusive of intern and resident didactic teaching and role-playing, ICU and ED initiatives, as well as educational sessions and satisfaction analysis for floor nursing and attending staff will be outlined.
15. Comparing Quality of Care of PCU, PCCT, and Usual Care Patients
Department of Geriatrics and Palliative Medicine
Icahn School of Medicine at Mount Sinai
New York, NY
Katherine Roza
Medical student
Icahn School of Medicine at Mount Sinai
1468 Madison Avenue, Annenberg Building, Floor 10, Room 10-02
New York, NY 10029
301-991-0068
Nathan Goldstein, MD
Diane Meier, MD
Katherine Roza, BA
16. ONE SIZE DOES NOT FIT ALL…Using “Palliative Care Rounding Tool” to assure Quality Interdisciplinary Care
Lee Memorial Health System
Fort Myers/Cape Coral, FL
Holly Lanier, MSN, ARNP
Lee Memorial Health Systems Q-life/Palliative Care
8960 Colonial Center Drive, Suite 206
Fort Myers, FL 33905
239-343-3639
Maria Isabel Lebron, MSW
Karen Washburn, MSW, ACSW
Andrew Esch, MD
The Q-life/Palliative Care services at Lee Memorial Health Systems was established in 2006 and continues to grow as evidenced by our inpatient hospital-based palliative care, our outpatient palliative care clinic, and the collaborative agreement with a local long-term care facility. The Q-life/Palliative Care program began in 2006 with 20 new inpatient referrals and finalized in 2012 with 4844 new inpatient referrals. Currently, we are functioning within four hospitals and anticipate over 5000 new referrals in 2013. One of the biggest obstacles within our rapid growth has been in maintaining quality care to our patients and families and meeting their individualized needs. Due to the success of the program and the result in growth, a “Palliative Care Rounding Tool” has been developed. Our Q-life/Palliative Care teams utilize this “Palliative Care Rounding Tool” daily in order to prioritize the needs of our patients and families. This tool identifies pertinent details such as; Symptoms, Advanced Directives and Determination of Health Care Surrogate, Psychosocial Issues, Spiritual Needs, Current Disposition, and most importantly the Patient's and Family's Anticipated Goals of Care. In order to meet the growing needs of our patients and families we have had to maximize the use of our interdisciplinary team members. Along with our core team of palliative care physicians, nurse practitioners and masters level social workers, our interdisciplinary team members include other health care system staff and volunteers: cancer navigators, expressive arts program, pet therapy program, grief counselors, child life specialists, translation services, transcultural advocate, massage therapist, accupuncture, psychiatrist, case management, home health, and spiritual services. Our tool assist in triaging patients/family needs, assuring that the appropriate discipline is seeing the patient/family to meet their specific needs and monitoring staffing needs. As we use this “Palliative Care Rounding Tool” on a daily basis we make adjustments in utilizing our core team, along with the other resources we have listed above, as this has proven to be a “better fit” for the patient/families that may be going through a very difficult time in their lives.
17. Telepsychiatric Care for Palliative Care Patients: An Opportunity
Lee Memorial Hospital System
Fort Myers, FL
Sherika Newman, MD
Lee Memorial Hospital System
8960 Colonial Center Drive, Suite 206
Fort Myers, FL 33905
239-343-9625
Pamela Schroeder, BSN, RN, OCN
Valerie Butram, MS, RD, CSO, LDN
Kristin Kardihy, PharmD
Gaby Brock, PharmD
William Pirl, MD
The quality of psychosocial care provided to patients with cancer has received increased attention since the 2008 publication of the Institute of Medicine (IOM) report titled, “Cancer care for the whole patient: addressing psychosocial health needs.” The report concluded that, despite evidence for the effectiveness of psychosocial care, many patients who could benefit from these services do not receive them. Often these services are not readily available or there are barriers to patients accessing such care. In a journal article from Forsyth in 2012 titled “Receipt of psychosocial care among cancer survivors in the United States” in the Journal of Clinical Oncology, the authors report on information collected from 1777 survivors of cancer. According to Dr. William Pirl (in his editorial, “Opportunities for improving psychosocial care for cancer survivors, jco.ascopubs.org, April 23, 2013): “The study yielded two major findings. First, only 40.2% of survivors reported having had a discussion with their providers about how cancer may have affected their emotions or relationships. Second, more than 90% of the barriers to the use of professional counseling or support groups identified by survivors involved lack of knowledge about, or unavailability of, services. Cancer centers and palliative care programs may need to identify local mental health clinicians and build working relationships and referral networks to address the problem of access.” In Lee County, Florida, there are too few psychiatric providers to meet the needs of the seriously chronically ill patient population and more so the ones that are willing often have long wait times before appointment availability and some may not possess the skill set to deal with the unique issues surrounding the seriously ill patient. Again, according to Dr. Pirl, “Telephone-based interventions represent another potential way to increase access when the availability of local mental health clinicians is limited. Kroenke et al. (“Effect of telecare management on pain and depression in patients with cancer: A randomized trial.” JAMA 2010;304:163–171) conducted a trial of a telephone version of collaborative care with mental health clinicians miles away and found that it, too, decreased depression. Although telephone-based interventions have yet to enter widespread clinical practice, promising work in psychiatric oncology teleconsultations is being done with experts at the Massachusetts General Hospital (MGH) Cancer Center (Boston, MA) collaborating with providers at the Lee Memorial Health (LMH) System (Fort Myers, FL).” The Lee Memorial Qlife Palliative Care program has access 24 hours a day, 7 days a week to the experts at the Massachusetts General Hospital department of psychooncology. LMH physicians, ARNPs and MSWs can, at any time, call the psychiatrists at MGH for real-time psychiatric teleconsultation on patients. Using distress scales such as HADS and PHQ 4, patients are identified and consultation is instituted. The consult includes presentation of history and physical exam, an interview with patient over the phone, and a full note within a few hours of intervention. MGH physicians have privileges at LMH and notes from the MGH specialist become part of the patient's permanent medical record. Follow-up is then conducted with the outpatient palliative care clinic. The MGH physician also conduct a onsite clinic at the LMH palliative care clinic every 6 weeks and in addition provide monthly psychosocial rounds via telephone to discuss topics and difficult cases.
18. Coordinating Quality across the PC Continuum
Lehigh Valley Health Network OACIS/Palliative Medicine
Allentown, PA
Elke H. Rockwell, PhD, MSS
Quality Specialist
Lehigh Valley Health Network
2166 S. 12th Street
Allentown, PA 18103
610-969-0597
Donna Stevens, BS
Daniel Ray, MD
19. An Outpatient Toolkit: System Approach to Best Practice
Levine Cancer Institute at Carolinas Healthcare System
Charlotte, NC
Niki Koesel, ANP, ACHPN
Director of Palliative Care, Levine Cancer Institute
Carolinas Healthcare System
1021 Morehead Medical Drive
Charlotte, NC 28204
980-442-5320
Eva Rodriguez, Practice Manager III
Carolinas Healthcare System (CHS) is the second largest nonprofit health care system in the United States and is committed to full integration of palliative, hospice, and end-of-life care. Levine Cancer Institute (LCI) is an integral part of CHS and now includes 12 sites across North and South Carolina; it is now expanding to deliver comprehensive cancer care including palliative care. In an effort to standardize and ensure excellent patient- and family-centered care, this toolkit was designed to guide the sites across LCI as outpatient oncology palliative care programs are developed to achieve this mission.
The toolkit utilizes national guidelines, professional organization statements, clinical tools and measures, and business planning to guide the successful integration of this service in becoming a standard part of comprehensive care offered to all patients across the cancer course. It can be shared electronically or in a manual format to serve as a resource and is meant to evolve and grow as the service availability grows within each setting. The clinical resources that are shared in the toolkit are designed using established best practices across the country that have been shared through organizations such as CAPC, NCCN, AAHPM, and HPNA. Documentation templates, training schedules for a multidisciplinary team, and symptom management guidelines are examples included in the toolkit of day-to-day needs that a growing program can utilize as teams develop their own practices. Unique to LCI, clinical pathways are utilized across cancer care to standardize practice. The LCI palliative care team has created clinical pathways related to symptom management and recommended integration of the services that are available to all LCI providers to promote both primary and secondary methods of palliative care.
As palliative care continues to grow across the country across all settings of health care it is imperative that best practices are shared among the specialty. This toolkit represents this effort in standardizing outpatient oncology palliative care across a large health care system and ensuring an expert working knowledge of professional standards, the evidence base and best clinical practices in order to promote an ongoing growth, and access to palliative care services across an ever growing patient population.
20. Pilot Study of Family Caregiver Burden in Home Hospice: Stress-induced Immune Changes and Their Implications on Caregiver Health
Mayo Clinic
Rochester, MN
Dr. Judith Kaur
Professor of Medicine
Mayo Clinic
200 1st Street SW
Rochester, MN 55905
507-284-3731
Abdullah Ladha, MD
Sarah J. Lee, MD
21. Regional Rural Advance Care Planning Initiative
Mayo Clinic Health System
Mankato, MN
Cory Ingram, MD
Assistant Professor Family and Palliative Medicine
Mayo Clinic Health System
1025 Marsh St.
Mankato, MN 56001
507-385-5794
Sheila Daggett (
A survey was conducted at the end of each of the evenings and the results will be displayed. Additionally, video responses from attendees were collected and will be shared. (Video is available at: www.youtube.com/watch?v=3nukQ63yGcs)
• 102 (52%) did not have an existing advance care planning document,
• 95 (48%) had an advance care planning document,
• 149 (76%) said the presentation and discussion had prompted them to consider creating an advance care plan,
• 46 (23%) expressed interest in having help in preparing their advance care planning document, and
• 40 (20%) expressed interest in being involved in a future effort to become an advance care planning ambassador.
22. Standardized Palliative Care Education and Screening
Mayo Clinic
Rochester, MN
Megan Voss, DNP, RN
Staff Nurse
Mayo Clinic
200 1st Street SW
Rochester, MN 55905
785-443-1003
Jennifer Smith, BSN, RN
Stephanie Slack, BSN, RN
This poster describes the efforts of developing a nurse-led educative consult focusing on palliative care and standardized screening in the inpatient hematology and oncology population. Literature supports initiating palliative care early on in diagnosis. When given the skill set and knowledge base, nurses can take the lead in this process. This initiative aimed to identify and initiate appropriate palliative care consults to: 1) increase quality of care, and 2) decrease moral distress and feelings of powerlessness among nurses. Nurses were surveyed with questions developed related to palliative care provided and provider interactions; distress was measured by a moral distress thermometer. The impetus for this initiative was unmet needs of patients, falling short of meeting current guidelines for providing palliative care, and nursing staff dissatisfaction. The number of palliative care consults ordered and feelings of moral distress were measured. Nurses were interviewed on their perceptions of process and education received regarding palliative care. Nursing staff retention is difficult in this specialty; therefore, a focus of this initiative was empowering nurses and relieving feelings of moral distress. Palliative care consults were increased by 17% and nursing moral distress decreased an average of 2.19 on the 0 to 10 Moral Distress Scale.
23. Preliminary Outcomes from a Quality Improvement Initiative to Enhance Palliative Care Resources in a Neurointensive Care Unit
Medical College of Wisconsin
Milwaukee, WI
Wendy L. Peltier, MD
Associate Professor
Medical College of Wisconsin
9200 W. Wisconsin Avenue
Milwaukee, WI 53226
414-805-4607
Tiffany Wolfgram, APNP
Denise A. Miller Niklasch, CNS
Brian Shields
Stephen Schilz
John Lynch, MD
Ann Helms, MD
24. Analysis of an Emergency Room Palliative Care Trigger Tool: Diagnosis and Barriers to Its Use
NSLIJ Health System–Lenox Hill Hospital
New York, NY
Bridget I. Earle, MD
Palliative Medicine Attending
Lenox Hill Hospital
100 East 77th Street
New York, NY 10075
212-434-4174
• No palliative care needs
• Palliative care needs due to (one or more of below):
1. Severe dementia
2. Severe CNS disease with progressive decline
3. Metastatic cancer
4. AIDS with progressive decline
5. CHF with recurrent admissions
6. COPD with recurrent admissions or requiring home O2
7. Severe advanced disease
8. Nursing home pt. with unclear care goals
9. Severe decline in functional status.
From February 2012 to April 2012 we conducted a retrospective review of the emergency room electronic medical record “EDIS” to measure the number of triggered patients. Our objectives were to identify the number of patient encounters triggered and consulted by the palliative team, describe the most common triggers used in both groups, and identify if there were any barriers or success to the use. The outcomes revealed the following:
• The total number of triggered patients was 155, of which 50 were consulted on by the palliative care team.
• The most common triggers were severe advanced disease (48%) and metastatic cancer (20%). CHF with recurrent admissions (1.9%), COPD with recurrent admission (1.3%), and AIDS (0.006%) were rarely used.
• Of the 105 nonconsulted patients, “physician refusal when on medical floor”(80 patients), “discharged when list was made” (16 patients), and “died” (7 patients) were the most common reasons for no consultation.
• The physicians who refused were most commonly from general internal medicine (67%), pulmonary critical care (22%), and cardiology (21%).
25. Palliative Care in University of California Intensive Care Units
Palliative Care Program, University of California San Francisco
San Francisco, CA
Steven Pantilat, MD
Director Palliative Care Program
UCSF
533 Parnassus Avenue
San Francisco, CA 94143
415-476-9019
Wendy Anderson, MD, MS
Kathleen Puntillo, RN, PhD
Jenica Cimino, BA
26. Identifying Core Data to Drive Quality Improvement
Palliative Care Program, University of California, San Francisco
San Francisco, CA
Steven Pantilat, MD
Director Palliative Care Program
UCSF
533 Parnassus Avenue
San Francisco, CA 94143
415-476-9019
Rebecca Burke
David O'Riordan, PhD
Betty Ferrell, PhD, MA
Peter Lindenauer, MD, MSc
Karl Lorenz, MD
Jeffrey Stoneberg
27. Neighbor, Teammate, Patient: A Preliminary Investigation of the Impact of Rural Culture on the Physician-Patient Relationship and the Impact of this Unique Dynamic on Subsequent Referrals to Palliative Care
Regional End of Life Network
Neosho, MO
Lori S. Cable, MS
Principal Researcher
Regional End of Life Network: Freeman Health System
1102 W. 32nd
Joplin, MO 64804
417-347-4963
Jeremy L. Sturgell, MD
Gwynn L. Caruthers, BSN, CHPN
Rural health care practice presents a unique mix of characteristics, which differentiates it from urban practice. To be accepted and trusted, the rural physician must be an integral community member and connect personal and professional life through informal social networks. Abiding by traditional ethical codes can pose challenges for the rural practitioner. Unavoidable dual/multiple relationships exist in these tiny communities where there is more livestock than people. The generalist comes in contact with patients anywhere he goes – church, school functions, grocery store. Complicating the issue, the provider may see extended family members as it is not unusual for it to seem that “everyone is related to everyone.” Handling confidentiality where anonymity does not exist is paramount. In these isolated communities, rural residents rely on their primary care provider. Access to larger health care systems is limited due to transportation barriers, economic disadvantage, distrust of outsiders, and a shortage of medical providers. Despite the rural reliance, little research is available about how the rural culture influences the relationship between the provider and the patient. Therefore, a dearth of information exists on the subsequent impact on referrals to palliative care. Preliminary results indicate that rural practitioners are less likely to refer than their urban counterparts as they are reluctant to “hand off” a patient to another provider due to a bond that has developed from the dual/multiple relationships that arise in the rural environment. Empirical studies are needed to investigate the perceived barriers and the effectiveness of methods to facilitate generalists in palliative care.
28. Application of an Integrated Multidisciplinary Approach to Skilled Palliative Care in the Home
Residential Home Health
Madison Heights, MI 48071
Jane A. Pozan
Therapy Supervisor
Residential Home Health
30755 Barrington Rd.
Madison Heights, MI 48071
248-524-6405
Melisa Swatowski
Michelle Ganci
The increase of patients with chronic disease, the pressure on hospitals to reduce readmits, and the reduction in payment for treatment has caused Residential Home Health to find new and innovative ways to provide quality care to our homebound palliative care patients.
• Significant improvement in their quality of life,
• Significant reduction in hospitalization rates, and
• Accelerated earlier admissions to hospice.
29. Team-driven Palliative Care Consults and Outcomes
Schneck Medical Center
Seymour, IN
Donna L. Butler, MSN, ANP-BC, OCN, ACHPN, FAAPM
Nurse Practitioner
Schneck Medical Center
411 W. Tipton Street
Seymour, IN 47274
812-523-7863
Rebecca J. Bartlett Ellis, PhD, RN
Brenda S. Smith, PsyD, HSPP
Patients with chronic disease and their families may experience significant life-disrupting complex symptoms, which are amenable to interdisciplinary intervention. Often these patients need palliative care services and do not meet the criteria for hospice care. To address this gap in service, our rural hospital developed an interdisciplinary palliative care program to meet the needs of patients with chronic diseases. Our interdisciplinary palliative care team is unique in that we consult on patients both in the inpatient and outpatient environments. We present a descriptive study of the outcomes of the program consultations over the last 6 months. Using a retrospective design, we reviewed the medical record and consult notes of the 81 patients who were evaluated by the team during October 2012 to March 2013 to describe the patient population and outcomes of this innovative program. Of those patients referred to the team, the primary chronic diseases included cancer (n=50), pulmonary disease (n=19), congestive heart failure (n=5), and a combination of other chronic diseases (n=7). Many times, palliative care is considered end-of-life care; however, we found that these patients had needs related to enhancing the quality of their life, rather than end-of-life care. Patients' life goals, identified during consultation focused primarily on improving their quality of life (44%) along with maintaining and improving functional status (32%), whereas only one patient wanted to focus on ensuring peaceful death. The primary goals identified by patients included cure of disease (n=6), comfort (n=8), and stabilization of disease (n=67), suggesting that a majority of our patients who self-manage their chronic disease needed assistance obtaining additional resources. As a result of our consultation, we were able to refer patients to multiple resources including: social work (n=38), chaplaincy (n=27), psychology (n=19), home health care (n=14), hospice (n=6), rehabilitation services and extended care (n=5), dietetic services (n=1), and smoking cessation counseling (n=1). With this program we were able to help patients identify resources they needed to help manage their disease. Our interdisciplinary team discussed advance directives with 84% of the patients and their families. We found that 68% of all patients (n=55) seen in consultation did not have advance directives at initial consult. Of those patients, 22% (n=12) received support from the team to develop advance directives. Eight patients who previously had a full code advance directive changed their code status to allow natural death after consultation with team members. This team-based approach allowed patients to talk about their concerns and future care decisions. Only two of the referrals were to clarify code status; however, more than half of patients and their families addressed code status concerns with the team after developing a relationship with team members. This highlights a significant need to create educational opportunities for patients and their families to understand their care and make appropriate informed decisions. In conclusion, the interdisciplinary palliative care team approach helps support patients in improving their quality of life both for the patient and their families by addressing their goals of care, their life goals, and advance care planning. The interdisciplinary team approach provides a service that facilitates involvement of the patient and their families in developing their care plan. This program is innovative in that it provides services to patients in both the inpatient and outpatient environments and the interdisciplinary team helps support patients and families to find meaning and purpose in the experience of chronic illness.
30. Palliative Care and Intensive Care CAN Coexist!
Scottsdale Healthcare
Scottsdale, AZ
Kathy Manske, RN, MSN, CCRN, CHPN
Palliative Care Nurse Clinician
Scottsdale Healthcare
7400 E Osborn Road
Scottsdale, AZ 85251
480-209-7914
One of the intentions of the Patient Protection and Affordable Care Act (ACA) of 2010 is to increase health care value by improving quality and decreasing costs. It also endeavors to reduce Medicare spending by $424 billion over 10 years, which will potentially involve payment reductions to providers. Palliative care clinicians are poised to play an important role as hospitals investigate methods to achieve sustainability and improved quality in the face of these reimbursement cuts. Evidence has repeatedly demonstrated palliative care clinician's ability to produce positive outcomes, not only related to reduced costs, but also to decreased length of stay and increased patient and family satisfaction. In an effort to maximize impact and optimize outcomes, a plan was developed at our hospital, whereby the palliative care team would concentrate efforts primarily in the intensive care unit (ICU). This would enable team members to focus their expertise on the most clinically and psychosocially complex, technology laden, and costly patients in the hospital. The ICU in question is a 45-bed unit located at a 337-bed level-one trauma facility. The palliative care team is a seven-year-old consultative service consisting of a full-time nurse and full-time social worker who are assisted by the house-wide chaplain and receive approximately 750 consults per year. Input and support for the plan was obtained from all stakeholder groups including nursing and hospital leadership, intensivists, trauma and neuro surgeons, and ICU management and staff via attendance at group, committee, and one-on-one meetings. An automatic consult trigger list was implemented to insure a greater percentage of appropriate patients were referred on a timely basis. The desired outcomes were decreased length of stay, reduction of unbeneficial or undesired interventions, potential cost savings, and increased consumer satisfaction. The support and expertise of the finance department staff was solicited to assist with determination of appropriate metrics, cost savings factors, and data collection. In the first 7 months after implementation, the percentage of ICU patients referred to palliative care increased from 12.8% to 16.6% and ICU length of stay decreased from 7.40 to 6.62 days over the same period last year. Day of admission to day of consult decreased from 6.09 to 3.81 days. Calculated cost savings were substantial. ICU bedside staff, intensivists, and trauma surgeons have expressed increased satisfaction with having palliative care more immediately available. These results serve as an example of the potential impact successful integration of palliative care into the ICU can have on outcomes. Lessons learned and strategies employed during the implementation of this plan can serve as a model for others as they move forward with the potentially difficult task of integrating palliative care into an intensive care unit.
31. Integrating Pediatric Palliative Care into Pediatric Oncology
St Jude Children's Research Hospital
Memphis, TN
Justin N. Baker, MD, FAAP, FAAHPM
Chief, Division of Quality of Life and Palliative Care
St Jude Children's Research Hospital
262 Danny Thomas Pl.
Memphis, TN 38105
901-595-4446
R. Kyle Wiser, MBA
Deena R. Levine, MD
Deborah Gibson
The trajectory of a pediatric palliative care program that has been integrated into a comprehensive cancer center is currently unknown. The purpose of this presentation is to document and assess the growth of the palliative care program over a 5-year time period and to examine key indicators reflecting improved quality of life for patients who have received care through the QoL Service at St. Jude Children's Research Hospital. A retrospective cohort study identified 457 patients seen at least once by the institutional palliative care service (Quality of Life [QoL] Service) between January 2008 and December 2012. The number of new patient referrals to the QoL Service has steadily increased from 52 in 2008 to 127 in 2012. The average number of visits per patient by the QoL Service also increased from 5.9 in 2008 to 10.9 in 2012. The amount of time from initial consult to death has increased from 44 days in 2008 to 149 days in 2012. From 2008 to 2010, 33% of the QoL Service new referrals had a primary goal of comfort and only 12% had a goal of cure. In 2011 and 2012, the percentage of new patients with a primary goal of comfort dropped to 16% and patients with an initial goal of cure increased to 28%. Additionally, there has been an increase in the number of patients dying with hospice (40% in 2008 versus 68% in 2012) and the patients are receiving hospice earlier than in the past (mean=25 days in 2008 versus mean=107 days in 2012). The percentage of patients dying with a DNR in the chart has been maintained above 80% throughout the study period, but there has been an increase in the number of days the DNR was signed before death (mean=24 days in 2008 versus mean=52 days in 2012). There has also been an increase in the percentage of St. Jude patients that received “expert level” palliative care before death. This “expert level” is considered to have been achieved if the patient is enrolled on hospice and/or was evaluated and followed by the QoL Service. In the first quarter of 2008, less than 30% of all St Jude patients that died received “expert level” palliative care. That number has now increased to 100% for the fourth quarter of 2012. The increased utilization of the QoL Service was brought about by many programmatic initiatives, including: creation of a model for palliative care delivery within the context of a strong medical home such as pediatric oncology, increased institutional resources, many educational sessions for all levels of trainees and health care providers, a trigger-based End-of-Life Care Project, creation of a family advisory council and elucidation of their institutional priorities for palliative care, implementation of a home health and hospice bridging program (QoLA Kids), creation of a bereavement program, the start of a multidisciplinary “liaison” team meeting, and the creation of a HPM fellowship. Each of these initiatives will be reviewed in this presentation.
32. “It's All in the How”—PC Continuum Reducing Readmissions
St. Joseph's Hospital and Medical Center
Phoenix, AZ
Jeanette Boohene, MD, FACP
Medical Director, Palliative Care
St. Joseph's Hospital and Medical Center
350 W. Thomas Road
Phoenix, AZ 85013
469-964-6757
Gobi Paramanandam, MD, MHSM
Francisco Cordova, MD
As we move toward the accountable care organization (ACO) model for providing health care, the need for better communication and coordination across the continuum of care becomes ever more crucial, in avoiding hospital readmissions. There is growing evidence that palliative care (PC) provided both in the hospital and the community impacts hospital readmissions positively. This small case series shows how avoiding hospital readmission happens in practice. Four patients, all with serious illnesses seen by the inpatient palliative care team at St. Joseph's Hospital and Medical Center (SJHMC) and referred on to a home palliative care team, Arizona Palliative Home Care (AZPHC), were able to achieve their goal of staying out of the hospital for the most part, while continuing in some cases to receive aggressive treatments. The key elements to the success of these “stories” were good communication between the hospital and home palliative care teams, with direct hand offs between the providers (MDs/NPs), usually via telephone or email communication, as the patients transitioned from the hospital to home, and the ability of the home palliative care team to address difficult symptoms and psychosocial needs quickly, often by a team member doing a home visit within a few days of the patient being discharged from the hospital. Through this type of communication, we were able to identify which member of the home palliative care team needed to see the patient urgently and what symptoms needed to be addressed immediately, such as pain, to avoid a crisis, which is often what triggers an emergency room visit or hospital readmission. With the paucity of community and outpatient palliative care services, it can be difficult to maintain the continuum of good palliative care that may have been started within the hospital setting by palliative care specialists. We have shown here that even without formal outpatient palliative care services within our hospital, collaboration and good communication with our community partners can impact our hospital readmission rates positively and together we can do more.
33. Perinatal Palliative Care: Beginning the Journey
Texas Health Harris Methodist Fort Worth Hospital
Fort Worth, TX
Leisha Buller
Coordinator for Palliative Care Services
Texas Health Harris Methodist Fort Worth Hospital
1301 Pennsylvania Ave.
Fort Worth, TX 76017
817-250-4924
As a tertiary referral center for women and infant's health in a large metropolitan area, our institution often receives infants with complex medical diagnoses. As such, we discovered a recurring theme among numerous families, which included the inability to articulate prognosis and comprehend all available treatment options, and frustration expressed with fragmented care received when transferring across health care settings. Together, these needs spawned the development of our perinatal PC program (weeCARE).
Our goals are comprehensive and heavily focus to establish a realistic plan of care through advance care planning (ACP), enhance communication, provide family support and education for healthy coping, and assist with ethical dilemmas. In the ACP process, our team expends extra effort to communicate each element of the ACP to numerous departments, ensuring that handoffs remain seamless and remain the expectation, not the exception. When delivery is planned at our facility, the weeCARE Team often attends the delivery and coordinates care with other departments including the Labor and Delivery Unit, the Pastoral Care Department, and the Gynecologic-Surgical Unit.
The weeCARE team collaborates and ensures that all providers receive the same information and, when permissible, will accompany mothers to other consultations, benefiting the mother and the weeCARE team. This ensures that all information received is accurate and the plan is in accordance with the wishes of the family. In fact, neonatal intensive care unit (NICU) admission has been avoided altogether in some cases. This has bestowed upon these families the precious memories and moments in time with their infant prior to death, instead of NICU admission. Without these crucial conversations, NICU admission is the likely outcome resulting in a course of treatment that is futile in many cases. Families often worry their child will suffer and experience pain, therefore another key focus of prenatal consultation when comfort measures are elected, is the plan for infant pain control, facilitating a peaceful end of life.
When infant death is anticipated, the weeCARE team provides information about the Mother's Milk Bank, a local breast milk bank, in which these mothers can donate their breast milk. This has given many mothers the opportunity to grieve their loss while also giving them the opportunity to help other infants, much like that of an organ procurement organization. Organ donation is also discussed, although most are ineligible to donate. Through an anticipatory grief assessment, the weeCARE team expertly provides bereavement support to families. In this, information about Caring Bridge, a nonprofit organization that employs the use of technology to communicate difficult information to numerous individuals is provided. Other local support group information is also provided to these bereaved families.
In the beginning, diagnostic triggers were identified and established to appropriately identify neonatal inpatients that would benefit from PC services in the NICU. As the service has gained momentum, the weeCARE team expanded to include outpatient, prenatal PC. With this continued growth, outcome measurements have evolved. Financial outcomes are weighted heavily and we must be able to provide evidence that our weeCARE team is a financial investment and fiscal responsibility within the organization. In substantiating our program, we continue to see the benefits, not only to our institution, but also to our patients and their family.
34. Innovative Palliative Care in the Intensive Care Unit
Texas Health Harris Methodist Hospital Fort Worth
Forth Worth, TX
Leisha Buller, MSN, RN, APRN
Coordinator for Palliative Care Services
Texas Health Harris Methodist Hospital Fort Worth
1301 Pennsylvania Ave.
Fort Worth, TX 76104
817-250-4924
Barrett Gabrielson, MS–Clinical Outcomes Specialist
Ashley Hodo, MSN, RN–Nurse Manager Palliative Care Services
As a 726 licensed-bed facility in a large metropolitan area, our institution often receives patients with a wide array of complex diseases, trauma, and medical diagnoses. Within our institution are five adult intensive care units (ICUs), each focusing on a unique specialty. In 2011, the total number of inpatient admissions to our facility was 36,068 and increased to 37,853 in 2012. Nearly 25% of all inpatient admissions are to the ICUs, thus the need for a well-integrated palliative care (PC) program throughout our facility cannot be over-emphasized. With nearly 40% of our PC consultation volume originating in the ICUs, it is no surprise that our program goals are comprehensive and heavily focus to establish a realistic plan of care through advance care planning (ACP), enhance communication, provide family support and education for healthy coping, and assist with ethical dilemmas. In the ACP process, our team expends extra effort to communicate each element of the ACP to family members and departments, ensuring handoffs remain seamless and continue to be the expectation, not the exception. The success of this ICU integration is founded in our continued commitment to continually engage physicians through collaboration. The core PC team attends weekly interprofessional rounds in each of the ICUs, offering bedside staff the opportunity to engage in open dialogue about their specific patient population, facilitating better understanding of PC services and what PC can offer patients and families who are facing life-altering, life-threatening, or life-limiting critical illness. Furthermore, this has helped bridge the gap that previously existed in the cardiovascular segment of patients; in fact, patients from cardiovascular services comprise nearly 40% of our total ICU consultations. A highly engaged, eclectic Critical Care Committee exists within our institution and PC is an essential discipline represented. Quarterly, PC-specific data are shared with this group, including the total percentage of deaths in each ICU with and without PC services and the number of consults originating in each ICU. Collaboration has driven process changes, including our withholding and withdrawing (WH/WD) process. Previously all patients choosing WH/WD remained in the ICU for this procedure, which is consistent across the nation. However, ingenuity and innovation has moved the WH/WD process out of the ICU and into the PC unit (PCU) in many cases. When the PC team provides consultation for patients, whose aggressive interventions are nearing the end or are futile, the WH/WD process is discussed, including the setting in which to proceed. Often patients are not projected to survive for any extended length of time following the WH/WD process, and these patients typically remain in the ICU. However, for those who are projected to survive beyond a few hours, discussion regarding the place of the WH/WD process ensues. Often these patients are moved out of the ICU into the PCU, where a homelike environment exists. This often provides families time and space for closeness and the ability to remain at their loved one's bedside in those final hours, a simple yet meaningful opportunity for closure. It provides cost-savings for our institution by moving the dying patient out of the ICU to make room for the more critically ill and improves throughput of patient flow from the Emergency Department. The recent novelty of PC as a specialty has inherent obstacles, not unique to our program, and involves: differentiating PC from hospice, educating staff, and identifying solutions to care fragmentation. Through successful ICU integration, the advantages to including PC in these populations have sparked an ever-growing momentum for further integration of PC into other sub-specialties, further understanding of PC, and a more robust, valuable service offered to patients.
35. Diverse Palliative Care Unified
Texas Health Harris Methodist Hospital Fort Worth
Fort Worth, TX
Leisha Buller, MSN, RN, APRN
Coordinator for Palliative Care Services
Texas Health Harris Methodist Hospital Fort Worth
1301 Pennsylvania Ave.
Fort Worth, TX 76104
817-250-4924
Palliative care services (PCS) at our 726 licensed-bed facility in a large metropolitan area received specialty certification for advanced PC through the Joint Commission (TJC) in November 2012. Our preparation left us to learn that two dichotomous teams, adult and perinatal, must form an unlikely partnership. In doing so, we determined that unity and homogeneity were essential. Our overarching goal in seeking certification was to provide patients and families the peace of mind that is associated with care provided by an accredited program. Moreover, as health care continues to change, the face of quality PC has never been more omnipresent than now. To accomplish this seemingly insurmountable task, each arm of PCS spent time learning about the other. To streamline PCS as a whole, we created standardized electronic medical record (EMR) documentation templates. Because each sub-specialty of our PCS is unique, templates were tailored to each specialty and to each discipline of the team (physicians, nurse practitioners, nurses, social workers, and chaplains). Our perinatal team (weeCARE) utilizes a PC consultation note and a PC progress note, much like that of the adult team, which utilizes the same notes but tailored to the adult patient population. Each of these templates pulls information from the EMR flowsheets and auto-populates this information into the notes, taking essential elements from the EMR that are critical to communicate in a progress note to other consulting disciplines. Given the inherent multidisciplinary approach that differentiates PC from other services, EMR templates were also constructed for our social workers and chaplains. All templates are constructed based on the Clinical Practice Guidelines for Quality Palliative Care (National Consensus Project, 3rd edition) and incorporate the essential elements specific to each discipline. Our PC program developed and implemented programmatic measures that are reported to TJC, including how to determine meaningful and effective communication both among our team and with our patients and families. Innovative methods have been implemented to aid in this determination through EMR documentation. Each of the note templates constructed are uniform yet contain information specific to the discipline utilizing it. Embedded within these templates are segments that highlight advance care planning and goals of care through family interaction. By employing this tactic, we have found that this is an essential element to incorporate because it provides a snapshot of the enhanced communication that is innate to PCS. This has helped our core team streamline conversations effectively, concisely communicate goals of care to other providers, and engage the decision maker in being an integral part of the health care team driving them to be decisive, rather than the historic process, which was largely led by the physician. Additional EMR documentation used by our team includes a template for our PCU interprofessional rounds. This template pulls pertinent information that the team discusses, such as advance directives, code status, and distressing symptoms that many patients experience. By auto-populating information into the note from the nurse's assessments, the team can quickly get a glimpse into distressing symptoms that the Edmonton Symptom Assessment Tool assesses for, such as dyspnea, anxiety, constipation, and secretions. This enables the team to discuss and help formulate a plan with the nursing staff, who then communicate with the attending physician. The fairly recent novelty of PC as a specialty has inherent obstacles, not unique to our program, and involves: differentiating PC from hospice, educating staff, and identifying solutions to care fragmentation. Through incorporating these unique populations into one service, the advantages have sparked an ever-growing momentum for further integration of PC into other sub-specialties, further understanding of PC, and a more robust, valuable service offered to patients.
36. CHF Patients: Would an Admission Checklist Increase Identification of Patients at High Risk for Unmet Palliative Care Needs?
The Ohio State University, Wexner Medical Center
Division of Palliative Medicine
Columbus, OH
Jeanette M. Abell, MD, MBA
Fellow, Hospice & Palliative Medicine
The Ohio State University, Wexner Medical Center
453 W. 10th Ave., 246 Atwell Hall
Columbus, OH 43210
614- 204-3370
Jeanette M. Abell, MD, MBA
Ellin Gafford, MD
Jillian Gustin, MD
The purpose of this study was to apply criteria developed by a consensus panel through the Center for the Advancement of Palliative Care (CAPC) to identify patients at high risk for unmet palliative care needs who could potentially benefit from specialty-level palliative care consultation at the time of their admission. This was a retrospective chart review of 218 Medicare discharges with the primary diagnosis of CHF discharged from OSUWMC between June 1 and November 30, 2012. Charts were reviewed utilizing a screening checklist designed to be initiated at the time of patient admission. All patients met the global criterion of having a “potentially life-limiting condition” – CHF in this group. They were then screened for the presence of primary and secondary criteria. Primary criteria are global indicators of the patient's condition including: the “surprise question”: “Would you be surprised if the patient died within 12 months?,” frequent admission for same diagnosis (within 3 months), difficult to control symptoms, complex care requirements, and decline in function. Secondary criteria are more specific indicators of unmet palliative care needs and include: admission from a long-term care facility, chronic home oxygen, out-of-hospital cardiac arrest, current or past enrollment in hospice, limited social support, and no history of advance care planning. Documentation during the first 24 hours postadmission was reviewed.
37. Collaboration between a Palliative Care Department and the Emergency Department Improves Early Access to Palliative Care
The Queen's Medical Center
Honolulu, HI
Claire Yoshida, APRN-Rx
The Queen's Medical Center
Pain & Palliative Care Department
1301 Punchbowl Street
Honolulu, HI 96813
808 691-4726
Matthew Ing, MD
Derek Uemura, MD, FACEP, FAAEM
Daniel Fischberg, MD, PhD, FAAHPM
38. Pediatric Hospice Experience in an Ethnically Diverse Community
TiLLiKids/Heartland
Miami, FL
G. Patricia Cantwell, MD
Professor and Chief, Pediatric Critical Care Medicine;
Director of Pediatric Palliative Care;
Pediatric Medical Director, TiLLiKids
Holtz Children's Hospital, Jackson Memorial Hospital/
University of Miami; TiLLiKids/Heartland
1611 NW 12th Ave., Holtz East Tower, Rm. 6006
Miami, FL 33136
305-585-6051
Shivani Tripathi, MD, Assistant Professor of Pediatrics, Division of Pediatric Critical Care Medicine, Holtz Children's Hospital, Jackson Memorial Hospital/University of Miami; Physician, TiLLiKids/Heartland
Lauren Owens, RN, RN Team Manager for TiLLi Kids
Laura Mandelbaum, LCSW, Licensed Clinical Social Worker
Leslie Hutchins, CCLS, Certified Child Life Specialist
Nicole Fernandez, RN BSN, RN Case Manager
Donna Sage, RN Case Manager
Carrie Feinroth, RN, MSN, Director of Professional Services
39. Transforming Patient Care within Long-term Care Facilities. Addressing the Symptoms: A Whole Person Centered Approach to Care
Treasure Coast Palliative Care
Fort Pierce, FL
Marisa Strong, MSW, RCSWI
Social Worker, Professional Relations Representative
Treasure Coast Palliative Care
5000 Dunn Road
Fort Pierce, FL 34981
772-341-9309
Dr. Bernice Burkarth
Barbara vanZyl, ARNP
Gusti Labatte-Deneau, ARNP
• Improved symptom management,
• Improved communication between the clinical team and the patient and family,
• Maximized facility stay by improving symptom control and management; the patients are able to participate in therapies,
• Improved quality of care by providing patients an extra layer of support providing information to allow the patient/family to make informed decisions in keeping with their values, beliefs, and desires,
• Assistance with complex cases by providing patients/families expert knowledge to assist in the clarification of goals of palliative care treatment options,
• Improved patient and family satisfaction,
• Assistance with clarification of goals in obtaining advance directives, and
• Assistance with clarification of do not hospitalize (DNH) and expediting DNH when consistent with patient and family goals.
In this study, we will discuss team coordination with facility multidisciplinary teams and referral sources, and assistance in transitioning to the long-term care facility setting from the hospital setting. This poster will focus on the relationship building with long-term care facilities by determining facility preferences and patient-specific needs while gaining acceptance and becoming part of the culture and treatment plan of the facility. We will also discuss how our program has become part of the facility including specific actions taken to make improvements in the services provided to the facility.
40. Psychosocial Distress: A New Palliative Care Trigger
San Francisco General Hospital and Trauma Center
University of California, San Francisco
San Francisco, CA
Heather A. Harris, MD
Associate Medical Director, Supportive and Palliative Care Program
San Francisco General Hospital & Trauma Center
1001 Potrero Avenue
San Francisco, CA 94110
415-206-3786
415-206-3786
Rachel Orkand, MSW
Carol Lam, MSW
Donald I. Abrams, MD
Anne Kinderman, MD
The American College of Surgeons–Commission on Cancer (CoC) is a consortium of professional organizations dedicated to improving survival and enhancing the quality of life for cancer patients. The CoC monitors the quality of comprehensive cancer care and oversees the accreditation of cancer programs nationwide. One of the means in which the CoC provides oversight is through the publication of a set of standards that accredited cancer programs must meet in order to gain and maintain accreditation annually. The CoC's latest set of standards, released in September 2012, will mandate psychosocial distress screening for all cancer patients within accredited cancer programs, to be phased in by 2015. This mandate offers the opportunity for greater partnership between palliative care programs and oncologists, for the purposes of meeting accreditation requirements and identifying patients who might benefit from earlier palliative care interventions. This poster will provide a detailed example of how palliative care leaders can assist their oncology colleagues in developing and implementing psychosocial distress screening, which can be used as a novel trigger for palliative care referral. San Francisco General Hospital and Trauma Center is the public hospital for the City and County of San Francisco and the primary safety net provider for residents of our city. Primarily though representation on our hospital's Cancer Committee, the Supportive and Palliative Care Program has been working with the Division of Hematology-Oncology and oncology social workers to help implement the CoC's new standard for psychosocial distress screening. In this poster, we will discuss the requirements of CoC Standard 3.2, as well as our collaborative efforts to: 1) select a screening tool and incorporate key modifications to better assess our unique patient population; 2) move an episode of screening into the inpatient setting, to address the needs of patients who receive their initial cancer diagnosis while hospitalized; and 3) trigger palliative care consultation for oncology patients found to have moderate to severe psychosocial distress, regardless of stage of disease or availability of treatment options We will also highlight the particular challenges of creating such a program in a resource-poor environment, with limited staffing and referral mechanisms to meet the substantial psychosocial needs of a diverse patient population. We will review relevant literature and share data from our oncology practice to describe the factors that contribute to high levels of psychosocial distress, including disease stage at presentation and multifactorial stressors more prominent in our practice setting. It is our hope that sharing our experience and alerting others to the CoC's mandates and standards will help catalyze similar collaborative efforts to support oncologists in the process of accreditation and, most importantly, in caring for their patients.
41. Emergency Department Experience with Advance Care Planning
University of California, San Francisco
San Francisco, CA
Heather A. Harris, M.D.
Associate Medical Director, Supportive and Palliative Care Service
San Francisco General Hospital and Trauma Center
1001 Portrero Ave.
San Francisco, CA 94110
415-206-3786
Joshua Lakin, MD
Eric Isaacs, MD
Erin Sullivan, MD
Rebecca Sudore, MD
42. Development of an ED Palliative Care Screening Tool
University of Florida College of Medicine/
Jacksonville Department of Emergency Medicine
Jacksonville, FL
Phyllis Hendry, MD
Assistant Chair of EM Research
University of Florida College of Medicine/Jacksonville
655 West 8th Street, Dept of Emergency Medicine
Jacksonville, FL 32209
904-244-4072
Phyllis Hendry, MD
Mark McIntosh, MD, MPH
Colleen Kalynych, MSH, EdD,
Sarah Osian, PhD
Nisha Patel, BS
43. Engineer in Palliative Care: Lean Process Improvement in Inpatient Palliative Care Consultation Service Targeting the Triage Process for New Consults
University of Iowa Hospitals and Clinics
Iowa City, IA
Mark Litterer
Lean Management Engineer
University of Iowa Health Care
200 Hawkins Dr.
Iowa City, IA 52246
319-356-1421
Joanne Gritton
• Understand baseline operations,
• Identify the amount of unnecessary communication/information,
• Reduction of time it takes to triage a new consult,
• Transfer tribal knowledge (undocumented work flow) into documented work flows, and
• Cross train members in order to effectively cover absences and vacations.
• Observe current state process and information to establish a baseline,
• Identify issues and bottlenecks by utilizing Lean Process Improvement tools and direct observations,
• Create a process and information flow map that outlines potential issues and bottlenecks,
• Identify “value added” and “nonvalue added” information,
• Refine the process and conduct a trial run of the new method, and
• Document the new process flow in visual standard work.
44. An Approach to Advance Palliative Care into the Heart Failure Clinic
University of Kansas Medical Center
Kansas City, KS
Lori Olson, MD
University of Kansas Medical Center
3901 Rainbow Blvd., 6040 Delp, MS 1020
Kansas City, KS 66160
913-588-3807
With an estimated 80 patients being admitted for acute decompensated heart failure each month at our institution, an approach to provide upstream palliative care in the existing advanced heart failure clinic was sought. This process was initiated when a palliative care physician joined the hospital's heart failure committee and began brainstorming integration. Utilizing the IPAL-OP needs assessment forms, a scope of care proposal for an outpatient embedded palliative care clinic was created. Goals of the clinic were established to: 1) impact advanced heart failure patients earlier in their disease process by discussing illness trajectory and goals of care as well as managing complex symptoms; 2) achieve better continuity for cardiology patients seen by the inpatient palliative care team through post-discharge follow-up, in conjunction with heart failure clinic providers; 3) assist in home-based resources for advanced heart failure patients to improve continuity and reduce hospitalization in this population; and 4) create educational opportunities for fellows and other trainees by providing exposure to goals of care and shared medical decision making in a subspecialty clinic. Bimonthly multidisciplinary meetings were held involving providers, nurses, managers, information technologists, scheduling, and administration to streamline workflow and minimize barriers including space, referral volume, primary palliative care education, and culture change. Heart failure providers identified volume need by assessing indicators in current heart failure patients. Indicators for palliative care referral were modified from the Supportive and Palliative Care Indicator Tool (SPICT). Palliative care physicians have begun seeing patients in conjunction with heart failure providers and will staff a half-day session a week beginning in fall 2013.
45. An End of Life Care Plan Increases Family and Staff Satisfaction with Pediatric Care at End of Life
University of Minnesota Amplatz Children's Hospital, Fairview
Minneapolis, MN
Paige Latham, RN, BSN, PHN
University of MN Amplatz Children's Hospital
111 E Franklin Ave. #317
Minneapolis, MN 55404
952-484-5601
Sarah Wiebler, CFLS
In order to streamline, define, and standardize what is available to children and families at end of life, Amplatz Children's Hospital has implemented the use of an End of Life Care Plan. This document serves several purposes and has facilitated critical discussions of family wants and needs when a patient is nearing end of life. In short, the Plan outlines services offered and provides an opportunity for families to chose items or procedures that they would find beneficial. These services range from aromatherapy and photography to assistance with funeral arrangements and other logistical needs. Outcomes continue to be extremely positive with many families expressing gratitude to nurses who use the End of Life Care Plan during a difficult time. Families feel more in control and are satisfied that their needs will be sought after and met. Staff appreciate the continuity that the Plan brings; it becomes an integral part of the nursing report, as items can be checked off as they are done. Finally, it provides comfort to extended family members who are visiting near time of death—they are reassured that needs of the immediate family members are being taken care of. This poster will outline the End of Life Care Plan itself, speak to how it is used in the acute care setting, comment on the interdisciplinary use of the Plan, and describe outcomes of the Plan at Amplatz Children's Hospital.