Tag Archives: outpatient palliative care

Enhancing the Value Proposition: Embedding Palliative Care Services in the Oncology Setting

By Susan van der Sommen, MHA, CMPE, FACHE

nurse and patient holding hands 2In a feature article in the January/February edition of Oncology Issues, Patsy Astarita, LCSW-C, OSW-C, and Michelle Abramowski, MSN, CRNP, share how the Kaufman Cancer Center in north central Maryland developed a palliative care program from the inside out. Though the existing infrastructure of the Kaufman Cancer Center included some palliative care resources, their challenges in developing the program were similar to those faced by other cancer programs: a dearth of existing funding, a navigation program focused on newly diagnosed patients rather than those at the end of life, and limited outpatient palliative care resources, among others.

Despite these challenges, the interdisciplinary care team at Kaufman Cancer Center garnered the requisite leadership support, performed a literature search of evidence-based best practices, and, building upon their existing resources, developed a palliative care program that has met its stated goals: reducing hospital use of chemotherapy at the end of life, while increasing early referrals to hospice and advance care planning. In 2016 Kaufman Cancer Center was recognized with an ACCC Innovator Award for their forward-thinking efforts expanding access to palliative care.

Often confused with hospice (utilized for end-of-life care), palliative care services are intended to provide a patient-centered approach to anticipating—and  thus reducing—pain and suffering, while improving quality of life by addressing the physical, social, emotional, and spiritual needs of the patient and family. According to a study performed by the American Society of Clinical Oncology (ASCO) Ad Hoc Palliative Care Expert Panel, patients with advanced cancer should receive “dedicated palliative care services” within eight weeks of diagnosis, offered concurrently with active treatment. The same study suggests that palliative care services offered early in the treatment process promote clarification of treatment goals, assistance with medical decision-making, enhanced care coordination, and a reduction in stress for the patient, family, and caregivers. Another benefit of introducing palliative care services early in the treatment process is cost reduction and savings through reduced hospital readmissions and emergency room use in the last 30 days of life.

To streamline their processes, the team at Kaufman Cancer Center developed a palliative care screening tool very similar to the psychosocial distress screening tool that has become familiar to most cancer programs in the United States. The five-question palliative care screening tool, now embedded in their EHR, has a 13-point scale that assists the care team in determining if the patient is appropriate for a palliative care referral. Embedding these services into their workflow is further enhanced by a weekly Palliative Care Conference during which team members discuss and review cases to determine next steps for patients and their family and caregivers. Also included in their ongoing programmatic development is a resiliency program to help support their staff as they work with patients during vulnerable times in their lives.

When working to initiate or expand palliative care services in the outpatient setting, most cancer programs face a host of challenges: lack of resources and/or budget; multiple, and sometimes conflicting, priorities; disparate and often disconnected programs. Despite these challenges, the team at the Kaufman Cancer Center did what cancer programs do best: put the patient at the center of their planning processes and developed a program that has improved care and satisfaction while reducing costs.


Contributing blogger Susan van der Sommen, MHA, CMPE, FACHE, is Executive Director, DSRIP, Bassett Healthcare Network, and Chair of the ACCC Editorial Committee.

Learn more about the ACCC Innovator Awards program here.

Building a Palliative Care Program from the Inside Out

By Michelle Abramowski, MSN, CRNP, and Patsy Astarita, LCSW-C, OSW-C

Palliative care has become an essential part of oncology care, particularly in patients with stage IV cancers, multiple co-morbidities, or advancing cancer despite treatment. The literature supports the value of collaborative oncology and palliative care services.1,2 While many cancer programs have developed outpatient palliative care clinics to meet this need, others may be challenged to offer these services on an outpatients basis.

At the Kaufman Cancer Center  we used existing resources to create a multidisciplinary outpatient palliative care program that addresses the care management and goals of our patients with advanced cancer. In October, this initiative will be recognized with a 2016 ACCC Innovator Award at the ACCC 33rd National Oncology Conference in St. Louis.


In a conference session on Friday, October 21, we will be sharing the “how to’s” of building a palliative care program by starting where you. Here’s a sneak peek at how we did it.

First Things First

Our first step was to identify existing challenges and strengths.

Challenges  

  • Inadequate communication between treatment teams
  • Lack of education related to palliative care
  • No budget
  • Documentation challenges and data management
  • Existing hospital palliative team focused on ICU
  • Patient navigation emphasis on newly diagnosed patients instead of palliative care
  • Reactive versus proactive use of resources.

 Strengths

  • Existing leaders and clinicians with a passion for palliative care
  • Creating a culture of sensitivity change
  • Existing inpatient palliative care program focused on improving quality outcomes and providing cost-effective care
  • Transitioning from fee-for-service to value-based care payer model.

Building Begins

In the summer of 2014, we formed a workgroup that included key members of our clinical team. We reviewed literature, evaluated existing models, identified national metrics, and selected specific outcome measures to track our progress.

In October 2014, we launched a weekly palliative care conference. This multidisciplinary conference includes oncologists, nurse practitioners, nurses, social workers, dietitians, and pharmacists. Every clinical area of the cancer treatment team is included and represented. Our team developed a decision-making tool to help identify patients in need of palliative care. The initial focus was patients with evidence of non-curative disease and/or an ECOG performance status of 2 or greater. Additionally, we incorporated use of Glare’s validated 5-item palliative care questionnaire.3

We identified key clinical team members willing to become palliative care experts within their discipline through personal education and the development of palliative care skills. This group of specialists meets bi-monthly to gain and share knowledge, develop new palliative care skills, and to monitor overall progress of our on-going effort.

Where We Are Now & What Lies Ahead

 As we near the two-year mark on this effort, we are seeing:

  • Fewer Emergency Department visits
  • Reduced ICU admissions
  • Earlier admission to hospice
  • Reduction in end-of-life chemotherapy
  • Earlier and more frequent “goals of care” meetings
  • Improved communication between patient, families, and treatment team.

And we’ve identified the following goals to continue moving our palliative care services forward:

  • Ongoing education and development of our palliative experts
  • Incorporation into multidisciplinary clinics
  • Updating patient educational materials
  • Improving community partnership
  • Continuing to track outcomes and identify new measures of success
  • Increasing visibility and awareness of our palliative care resources.

Four Lessons Learned

Our experiences building our palliative care services have taught us:

  • How to use valuable existing resources
  • Early palliative care intervention improves outcomes
  • Invite everyone to participate—multidisciplinary expertise is vital
  • Secure support from leadership early in the process.

How About You?

Our patient-centered model of palliative care is a continuous process that focuses on our patients’ values, beliefs, and wishes for end-of-life care. Discover what talent already exists in your cancer program that can help reduce patient suffering, improve quality of care, and make best use of your resources. Can you create a program from the inside out?

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References

1Temel J, Greer J, et al. Early palliative care for patients with metastatic non-small cell lung cancer. N Engl J Med. 2010;363:733-742.http://www.nejm.org/doi/pdf/10.1056/NEJMoa1000678
2May P, et al.  Prospective cohort study of hospital palliative care teams for inpatients with advanced cancer: Earlier consultation is associated with larger cost-saving effect. J Clin Oncol. 2015;33, 1-8.
3Glare, et al. Palliative care in the outpatient oncology setting: evaluation of a practical set of referral criteria. J Oncol Pract. 2011;366-370.  www.jop.ascopubs.org/content/7/6/366.full


Michelle Abramowski, MSN, CRNP, is nurse practitioner, and Patsy Astarita, LCSW-C, OSW-C, is manager, Supportive Care & Community Services, UMD Upper Chesapeake Health, Kaufman Cancer Center.

 

Palliative Care: Patient-Centered Support

By Sandy Balentine, MSN, RN, OCN, MBA

HC provider cupping patients hand (for web)The understanding that palliative care is not hospice care has been, and continues to be, a challenge for both patients and providers to grasp. Palliative care is “. . . specialized medical care for people living with serious illness. It focuses on providing relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family.”1  Palliative care is appropriate at any age and at any stage of a serious illness. It is offered alongside—not instead of—curative  care.

Hospice is a philosophy of care for people who are near end of life and are no longer seeking curative treatment.

Palliative Care—Part of Team-Based Care

The role of palliative care is to treat pain and other symptoms, and help patients realistically review the goals of their care. Clinicians trained in the subspecialty of palliative care work together with the patient’s disease-directed care team, helping to better meet the patient’s needs with a team-based approach. The team includes nurse practitioners, physicians, social workers, dietitians, chaplains, pharmacists, registered nurses, and others. The team helps patients gain control of their illness by exploring their goals of care, better understand their treatment options, and avoid unwanted care.  A partnership develops that includes the palliative care team, the patient, and the patient’s family. Patients are relieved to have help with understanding what to expect and how to handle it, and difficult decisions can be made with more information and insight.  Palliative care can help patients and their families cope with the challenges of living with a serious illness. Family members receive support, and as a result feel they can, in turn, better support their loved one.

A Focus on Quality of Life

A pivotal study of patients with metastatic NSCLC by Jennifer Temel and colleagues demonstrated that early palliative care showed significant improvements in quality of life and mood, as patients received less aggressive treatment at end of life but experienced longer survival.

The Institute of Medicine’s (IOM’s) 2013 report, Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis, cites the need for improved access to palliative care for patients with cancer, noting that:

“Care often is not patient-centered, many patients do not receive palliative care to manage their symptoms and side effects from treatment, and decisions about care often are not based on the latest scientific evidence.”

At Valley Hospital, we recognized the difference that palliative care can make in the quality of life for our cancer patients.  We started with an inpatient palliative care program and today also offer palliative care in the outpatient setting or for homebound patients at home in the privacy of their residence. This service is an extra layer of support for an improved quality of life for our patients.

Growing Services to Meet Patients’ Needs

By the end of 2014, our inpatient palliative care service was extraordinarily busy, and the team knew that this service needed to be available to patients before they were admitted to the hospital in a crisis situation. With improved symptom management, hopefully some of these patients could avoid being admitted to the hospital. So we began the process of developing a palliative care service for our outpatients. Our first step was to put together a multidisciplinary weekly meeting that included a psychiatrist, pain management physician, palliative care nurse practitioner, chaplain, pharmacist, social workers, registered nurses and others. This team would review cases and give input and recommendations, combining the joint knowledge of the group. Patients were identified through the physician practice providers, Infusion Center or Radiation Oncology staff, or by self-referral.

As we began to develop the outpatient program, it quickly became obvious that there was a population whose needs we were not meeting. These patients were homebound or had an extremely difficult time getting in to the office.  Still, these patients needed the support that palliative care could provide. To meet this need, our home care agency has now started to integrate palliative care support to our homebound/home care patients as well.

Improving Access for All

Although great strides have been made in palliative care in the last few years, access to these services remains uneven. Palliative care is not available in many smaller hospitals or in rural areas. According to a 2015 report from the Center to Advance Palliative Care (CAPC), Alabama is one of the states with the lowest access, with less than one third of hospitals offering palliative care.  Reasons for this low coverage include a lack of knowledge about palliative care among healthcare providers, socioeconomic factors, geographic factors, transportation issues, and other factors. CAPC is a national organization dedicated to increasing access to quality palliative care for people facing serious illness. CAPC has helped the advancement of palliative care services by providing tools, training, and technical assistance to clinicians as a catalyst to change the conversation around palliative care.  CAPC’s vision is simple: to have palliative care available everywhere.

To ensure that health professionals understand the quality of life issues that exist for their patients, students in medicine, nursing, social work, psychology, and pastoral care, all need to have a robust educational program to help them understand what palliative care encompasses and how it can help patients. This training needs to include early lessons on discussing end-of-life decisions, how to handle anger and sadness from families, and how to respond personally to the loss of a patient. Only then will we be able to approach CAPC’s vision of palliative care available to every patient.

Stay tuned for an upcoming blog from 2016 ACCC Innovator Award winner University of Maryland Upper Chesapeake Health, Kaufman Cancer Center on how to build a palliative care program “From the Inside Out.”

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Reference
1Center to Advance Palliative Care.  About Palliative Care. Available at www.capc.org/about/palliative-care.


ACCCBuzz contributing blogger Sandy Balentine, MSN, RN, OCN, MBA, is the Director of Clinical Oncology at ACCC Member Program, The Valley Hospital.