Palliative Care Office Hours for Patients with Hematologic Malignancies: An Innovative Model for Symptom Management and Education

Abstract

Background:

Palliative care programs are experiencing rapid growth, with demand for consults surpassing staffing. Innovative models are needed to equip nonpalliative care providers to manage basic palliative care issues.

Objectives:

To develop a novel program of palliative care office hours for hematologic oncology advanced practice providers, and to evaluate its impact on palliative care consult volume and composition.

Methods:

A palliative care nurse practitioner or pharmacist was available for weekday office hours to all inpatient hematologic oncology advanced practice providers at an academic medical center to offer advice on pain, nonpain symptoms, and psychosocial distress. A retrospective study looking at outcome measures after six months of office hour utilization and palliative care consults from the hematologic oncology services.

Results:

Palliative care office hours had a mean duration of 16 minutes per day (range 5 to 55). A mean of 11 patients were discussed per week (range 4 to 20). Pain, nausea, and anxiety were the issues most frequently raised. Of 299 patients discussed during office hours, 44 (14.7%) subsequently required a full palliative care consult. Overall, palliative care consults from the hematologic oncology services decreased from 19.6% to 10.2% of admissions (87/445 vs. 61/594, p < 0.001) with an increase in consults for goals of care.

Conclusion:

Office hours are an efficient way to address palliative care needs when demand for palliative care consults exceeds capacity. Office hours may serve an educational function as well, enabling primary teams to manage basic palliative care issues with increasing independence over time.

Introduction

Many palliative care programs are experiencing rapid growth requiring corresponding increases in staffing.¹ Despite this increase in palliative care capacity, the current palliative care workforce is insufficient to meet the needs of all patients with serious illness.² Many experts advocate for greater focus on education to equip nonpalliative care practitioners with basic skills in pain, symptom management, and goals of care communication while palliative care specialists focus on refractory symptoms and difficult conversations.^2–4 This is especially relevant for populations with a high prevalence of palliative care needs and settings with limited palliative care resources.

Patients with hematologic malignancies are one population with a high prevalence of palliative care needs. Treatment for hematologic malignancy requires repeated hospitalizations for induction chemotherapy, consolidation chemotherapy, or stem cell transplantation. These treatments are associated with high symptom burden, and patients report an average of eight symptoms during treatment.^5–7 Patients also experience psychological distress related to prognostic uncertainty, prolonged hospitalizations, and complex decisions. Despite these challenges, palliative care consultation occurs late in hematologic malignancies.^8–10 Recent research indicates that earlier palliative care can improve quality of life during and after hospital stays for this popoulation.¹¹

With increasing evidence for palliative care, innovative models are needed to equip nonpalliative care clinicians with basic palliative care skills while ensuring that complex patients still receive consultation by a palliative care specialist.^12,13 Our study describes a novel pilot of palliative care office hours that was implemented to balance primary and specialist palliative care for patients with hematologic malignancies. We evaluated the office hours program for (1) feasibility, (2) utilization by referring providers, and (3) impact on palliative care consult volume, composition, and outcomes.

Methods

Before initiation of office hours, hematologic oncology services were the largest source of palliative care consults at our institution, with a majority of consults for pain, nonpain symptoms, and psychosocial distress. Patients on these services are physically located on four oncology units, and care is provided by a closed group of ∼20 advanced practice providers who work in collaboration with attending physicians. Most patients are admitted for active therapy such as chemotherapy or stem cell transplantation. The remaining patients are admitted with a complication such as infection or bleeding.

Study design

An “office hours” program was started in March 2015 as a strategy to encourage primary palliative care. The hematologic oncology services were chosen due to their large consult volume, predominance of symptom management consults, and closed provider group. After approval by oncology leadership, the program was advertised via email, individual conversations with providers, and discussion at an oncology meeting. To encourage utilization, oncology advanced practice providers were required to attend office hours before placing an order for a palliative care consult.

To perform office hours, a palliative care nurse practitioner and/or pharmacist went to the inpatient hematology-oncology advanced practice offices daily at a consistent time to discuss patients and answer questions. Discussion typically included medication recommendations, resources for patient/family support, and informal education. A full consult was subsequently performed for complicated cases that could not be adequately addressed in office hours. Consults were automatically performed when goals of care or spiritual distress were identified as issues, since they are less easily addressed in “curbside” consultation. Oncology providers were free to participate each day or not, depending on their patients and preferences. The palliative care provider stayed until all questions were answered.

Data collection

Daily records were kept by the palliative care provider performing office hours. Detailed information was recorded about duration, number of advance practice providers present, topics discussed for each patient, and whether a full palliative care consult was recommended.

The palliative care service's internal database was queried retrospectively for palliative care consults from the hematologic oncology services during the six months before and after implementation. Hematologic oncology service volumes were obtained from hospital administrative data.

Data analysis

Descriptive statistics were used to characterize the patients discussed during office hours and utilization by referring providers. Odds ratios were used to compare palliative care consults from the hematologic oncology services before and after implementation of office hours. Stata statistical software (Stata MP2 version 11.0) was used for all analysis. The University of Pennsylvania Institutional Review Board provided approval for this study.

Results

Office hours were well attended, with an average of five advanced practice providers (range 0 to 11) participating each day. Office hours lasted an average of 15 minutes (range 5 to 55). Pain was the topic most commonly discussed, followed by nausea, anxiety, and depression (Table 1). Of 299 patients discussed during the first six months, only 44 patients (14.7%) subsequently received a full consult.

Table 1.

Utilization of Palliative Care Office Hours During First Six Months of Implementation

Utilization statistics
Total number of patients discussed	299
Average number of patients discussed per week	11 (range 4–20)
Average duration of office hours in minutes per day	16 (range 5–55)
Average number of advance practice providers who attended office hours each day	5 (range 0–11)
Topics discussed during office hours^a
Pain	119
Nausea/vomiting	70
Anxiety	58
Depression	32
Delirium	9
Diarrhea	7
Insomnia	5
Appetite	3
Constipation	3
Dizziness	3
Secretions	2
Cough	1
Indigestion	1

More than one topic may have been discussed per patient. Goals of care and spiritual distress were not addressed in office hours; full palliative care consults were provided for these needs.

Implementation of office hours resulted in a significant decrease in palliative care consults from the hematologic oncology services (10.2% vs. 19.6%, of admitted patients, p < 0.001). Additionally, the office hours program changed the composition of palliative care consults with fewer consults for pain and more consults for goals of care (Table 2). The program had no impact on the dispositions of patients following palliative care consultation (Table 2). Specifically, there was no impact on the number of patients referred to hospice from the hematologic oncology services.

Table 2.

Impact of Palliative Care Office Hours on Palliative Care Consults

	Six months before start of office hours, n (%)	Six months following start of office hours, n (%)	Odds ratio (p)
Total discharges from hematologic oncology advanced practice services	445	594	—
Total number of palliative care consults from hematologic oncology advanced practice services	87 (19.6)	61 (10.2)	0.471 (<0.001)
Reason for palliative care consult^a
Pain	49 (11.0)	16 (2.7)	0.276 (<0.001)
Nonpain symptoms	31 (7.0)	20 (3.4)	0.881 (0.720)
Psychosocial or spiritual distress	42 (9.4)	39 (6.6)	1.899 (0.059)
Goals of care	1 (0.2)	7 (1.2)	11.148 (0.009)
Disposition after consult
Hospice	4 (0.9)	7 (1.2)	2.690 (0.201)
Home health services	41 (9.2)	26 (4.4)	0.833 (0.588)
Home without services	2 (0.4)	5 (0.8)	3.795 (0.125)
Rehab or LTACH	13 (2.9)	7 (1.2)	0.738 (0.544)
Sign off before discharge	27 (6.0)	14 (2.4)	0.66 2 (0.279)
Died in hospital	0	2 (0.3)	— (0.168)

Consults may be requested for more than one reason.

LTACH, long-term acute care hospital.

At the conclusion of six months of office hours, feedback was solicited from the hematology oncology and palliative care providers via email and in-person meetings. Both groups cited increased collaboration between the groups and improved understanding of which patients need a full consult. The office hours program was extended indefinitely.

Discussion

In this study, a palliative care office hours program for hematologic oncology services was feasible and well accepted. It led to a significant and lasting decrease in consults, with fewer consults for pain and more consults for goals of care. Importantly, complex cases still received full consults since palliative care clinicians were able to triage all potential consults in the context of office hours. This resulted in efficient use of palliative care resources during a period of rapid palliative care service growth.

This program had the additional benefit of increasing collaboration and collegiality between palliative care and hematologic oncology providers. Office hours led to teaching opportunities for the hematologic oncology services including a formal one-hour didactic on pain management. Office hours also provided a chance to collaborate on active consults and increased communication between teams.

Our study institution may be unique in the high volume of palliative care consults for patients with hematologic malignancies. Other institutions may want to perform full palliative care consults for all patients with hematologic malignancies to encourage palliative care contact with this population. Nevertheless, the office hours model is likely to be successful with other populations when the following criteria are present: (1) high volume of palliative care consults from a single referring service, (2) significant proportion of consults for pain, symptom management, and issues amenable to discussion in office hours, (3) centralized location for patients or providers, and (4) engaged leadership willing to promote office hours.

This study does have important limitations. First, office hours require a daily time investment by a palliative care clinician. In our study, office hours were performed by a nurse practitioner or pharmacist, but some institutional cultures may desire palliative care physician participation. We believe that the time investment (daily median 10 minutes) was justified by the opportunity for primary palliative care education.

Second, discussing patients in office hours without a consult results in lost billing opportunities. This may be an unacceptable trade-off for palliative care programs with low consult demand relative to staffing. For programs with demand in excess of staffing, missed billing may not be an important consideration since billing opportunities are already missed regularly. In these settings, office hours may assist with triage to ensure that consults with the greatest potential impact are prioritized.

Lastly, providing recommendations without seeing patients may increase the risk of adverse outcomes and liability. The palliative care clinician has to rely on information from another clinician when formulating recommendations. Office hours should be staffed by experienced clinicians who are comfortable managing patients without direct contact. In addition, the palliative care clinician must request a full consult in high-risk situations and unclear clinical scenarios. It is helpful for the palliative care provider to have access to the electronic medical record during office hours to verify current medications, labs, and allergies.

This study did not include formal mechanisms to assess referring provider satisfaction or the impact of the program on palliative care knowledge among hematologic oncology providers. Additional research is needed to determine the educational impact of the program and long-term impact on the practice culture of hematologic oncology services at our institution.

Despite these limitations, the office hours program is a simple and effective model to integrate primary and specialty palliative care for populations with a high prevalence of palliative care needs. It is also an effective tool for building relationships with referring services, especially in settings with limited palliative care resources. Future studies should examine implementation in different patient populations and alternative practice settings such as clinics and long-term care facilities.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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