Growth of hospital-based palliative care programs surges
Growth of hospital-based palliative care programs surges
Programs meeting the specialized needs of patient population
If your hospital doesn't have a palliative care program it soon may, if current statistics are any indication. The New York City-based Center to Advance Palliative Care's (CAPC) analysis of data released in the 2007 American Hospital Association Annual Survey of Hospitals shows that 1,240 hospitals now provide palliative care programs. According to CAPC, the total in 2000 was 632.
CAPC adds that of the 4,103 hospitals "appropriate" for palliative care programs (psychiatric and rehab hospitals are excluded):
- 30% have a program.
- 50% with more than 75 beds have a program.
- 70% with more than 250 beds have a program.
- 57% of hospitals with a cancer program approved by the American College of Surgeons (ACS) have a program.
- 75% of Council of Teaching Hospitals (COTH) members have a program.
- 46% of hospitals in cities with a population of 1 to 2.5 million have a program.
The cause of this rapid growth is "multi-factorial," according to Diane E. Meier, MD, director of CAPC, director of the Lilian and Benjamin Hertzberg Palliative Care Institute, and the Catherine Gaisman Professor of Medical Ethics Professor, Departments of Geriatrics and Medicine, Mount Sinai School of Medicine. "One of the major causes is the growth in the number of patients who live with serious chronic, multiple comorbid illnesses but who do not become well," she says.
"They are completely technology-dependent, requiring dialysis or ventilators. They do not die, but live on, tethered by various machinery, but they do not go home. Another key factor is the enormous investment of the Robert Wood Johnson Foundation in the center, and other initiatives that have blanketed the country with information and training for doctors, nurses, and technical assistants."
CAPC defines palliative medicine as "interdisciplinary care aimed at the relief of the pain, symptoms, and stress of serious illness." Its goal is "to ensure the highest quality of life possible for patients and their families."
Why a specialized program?
But these patients already are being treated in hospitals; why is a specialized program required? "This group of patients is really not well served by standard treatment in hospitals," Meier asserts. "They work very well for the average patient, but they do not work well for the smaller number of outlier patients who are the most sick and typically have comorbid illness. They tend not to do well and are enormously costly for hospitals, so palliative care is needed for this small number of high-level suffering patients."
These patients, she continues, require "comprehensive and expert symptom assessment and management." Sophisticated communication skills are required to help seriously ill patients and their families understand what their real choices are, she explains.
"You have to give them the information they need and support them in their choices," says Meier. "If their prognosis is limited, they may choose to spend their remaining weeks of life at home, as opposed to languishing in the ICU for weeks or months. If they are unable to come off a ventilator, once the family understands that this means the patient is unlikely to ever come off it, they may choose to remove them from the ventilator."
What a program looks like
The structure of the palliative care team can vary based on the size of your hospital, notes Meier. "If you have 300 beds or more, the interdisciplinary team at a minimum usually includes a nurse, a social worker, and a physician," she says. "Preferably, they have some form of advanced training and accreditation."
They usually are admitted by referral from their primary care provider, says Meier. "Some hospitals have screening programs with specific criteria, such as stage 4 metastatic cancer, or hospitalization of longer than two weeks, which are triggers for referral," she adds.
Mount Carmel Health System in Columbus, OH, has palliative care programs in all three of its hospitals, and all have similar staffs, notes Mary Ann Gill, MA, RN, executive director for palliative care services. "The units are staffed by hospital employees who have a primary interest in palliative care and may also work in another unit," she says. The interdisciplinary team includes nurses, social workers, pharmacists, and chaplains. "The palliative consult service includes a palliative care physician and/or tenured nurses," she adds. "They round every day in a structured rounding process and reassess patients every 24 hours; they also see patients in the rest of the hospital."
"By the very nature of palliative medical service, a huge part of it is communication and coordination between all disciplines and sub-specialists," notes Philip Santa-Emma, MD, medical director, palliative care services at Mount Carmel. "Being primarily a hospital-based program, we are able to be there when the families are there and we have the time, the expertise, and the skill set to meet with families and understand multiple issues — and integrate the care away from the subspecialty focus to the patient as a whole. This way, we really help bring the big picture into focus and develop a plan of care that utilizes the resources we have — and uses them for the most appropriate form of care."
Creating a program
The Mount Carmel program began operating in 1997, Gill recalls. Prior to that, she was the director of a community hospice owned by the Mount Carmel system. "I attended a conference in Phoenix where people were talking about pain management in hospitals," she recalls. "The folks who were there from hospitals were very surprised by what they heard, but I wasn't. This made me think about the knowledge gap in hospitals."
She started working with hospitals in her system, sharing evidence-based information. "We realized we did have some information that was useful to hospitals, but that we also had a lot to learn about their needs," Gill says.
After learning more about chronically ill patients in hospitals from these discussions and from the Support study (which was conducted from 1990 to 1994 at five different university hospitals around the country and which evaluated how end-of-life patients were dying), Gill put together a group of physicians and asked if they would consider looking at a new and different program for this patient population. "We started working on a pilot program and began looking at programs that had already been started; Northwestern was our benchmark," she says. "We went there and studied them."
She was fortunate, she says, that experts were available within the Mount Carmel system. "We started with small bits and pieces of FTEs," says Gill. "We felt physician presence was important because they tend to be the people who either open doors or keep them closed to referrals."
As the program grew, so did the FTEs. "We started two units; our rationale then was to have those units and train staff to be competent in pain management. Within the next three years, the system had another hospital and we now have three units."
The program interfaces with the quality department, but it also has a database of its own, says Gill. "Since it's a new program, we wanted to be able to track what happens with our patients," she explains. The program has a rounds worksheet that helps keep track of patients' diseases and symptoms, and those data go into the database.
"We also have some benchmarking measures we keep and that we feel are very important," adds Gill. "We collect them, analyze them, keep them on a dashboard, and report to the centralized quality committee."
Mount Carmel also compares its performance with other facilities, says Gill. "We want to make sure we manage basic pain and key symptoms within a specified period of admission — for example, within 48 hours we should address and reduce pain and order other, appropriate pharmacological therapy," she says.
Quality measures also include conducting family meetings to gain consensus on how care should proceed; showing evidence of care coordination; and making sure discharge planning is being used by day 3 (average LOS is 3.6 days).
To ensure the highest possible quality in a palliative program, Meier advises quality professionals to examine the criteria, standards, and guidelines that underlie a good palliative care program and identify the "crosswalks" between different standards organizations. (CAPC provides a list of guidelines as well as charts illustrating these crosswalks on its web site, www.capc.org.)
"This way, you can help the palliative care team to integrate into their clinical work the measurements and reporting that are the bread and butter of a quality expert," she explains. "Help them establish guidelines and learn how to measure and put in place QI for areas in which you fall short. This is imperative."
If your hospital doesn't yet have a program, you can learn about how to negotiate with your administration on the CAPC web site, says Meier. "Once you get started, be aware there is a huge range of programs, quality, and adherence to guidelines," she add. "Support the growth and development of your program to help make it as good as you can."
Outcomes improve
Gill says she has seen considerable improvement in outcomes with the institution of the palliative care program. "One of the things we saw before the program was that these patients did come in the hospital and stayed for a long time, but given all that time and effort, they did not necessarily have great outcomes; they still had a high potential for dying in the hospital and not being transferred to hospice care," she says. "Even if they were not appropriate for hospice, they needed to be managed uniquely, but we could see they spent a lot of time in uncoordinated care, or staff did not have time for the family to express what their wishes were."
The old data, she continues, showed that patients who were very sick — with end-stage heart disease or lung cancer, for example — spent their last 10 days in the ICU and died there. "Now, when they enter the ED, they may go to the ICU, but there will be a palliative care discussion," she notes. "The ED now has specific triage triggers for such discussions." If they go directly into palliative care, she says, "We can reduce their symptoms, keep them stable, and discharge them in three or four days. Previously, they would be here for 10 to 13 days."
Gill says the program has had a positive impact not only on quality, but on utilization, volume, LOS, occupancy on units, and overall patient flow.
Patients and their families have a positive perception of the program, says Gill. "When we ask them if they would recommend this care to someone else, 85% say they definitely would," she notes, adding that these responses come both from families of patients who died and from families of patients who were discharged.
The keys to a successful program, says Gill, begin with a strong team. "You really need interdisciplinary involvement, and a good balance of doctors and nurses," she says. "I also think programs struggle if they do not have a clearly articulated plan for growth, because growth will occur fast, and you don't want to burn out your staff." Gill knows whereof she speaks: Her program has been designated as a Palliative Care Program of Excellence by the Robert Wood Johnson Foundation, and has been asked to train other health care systems to start their own palliative care programs.
Having good data also is critical to your program's success, says Santa-Emma. "There will come a time when the system comes and says, 'What are you doing and how well are you doing it?'" he points out. "If you do not have the data, all you can say is that it feels good, or, 'The patients like us.' You'll never survive with that; being able to describe your program in detail to anyone who asks is vital to showing the value your program has to the system as a whole."
For more information, contact:
Mary Ann Gill, MA, RN, Executive Director for Palliative Care Services, Mount Carmel Health System, Columbus, OH. Phone: (614) 234-0226.
Philip Santa-Emma, Medical Director, Palliative Care Services, Mount Carmel Health System, Columbus, OH. Phone: (614) 234-0200. E-mail: [email protected].
Diane E. Meier, MD, Director, Lilian and Benjamin Hertzberg Palliative Care Institute; Director, Center to Advance Palliative Care; Catherine Gaisman Professor of Medical Ethics Professor, Departments of Geriatrics and Medicine Mount Sinai School of Medicine, Box 1070, New York, NY 10029. Phone: (212) 241-1446. Fax: (212) 426 5054.
If your hospital doesn't have a palliative care program it soon may, if current statistics are any indication. The New York City-based Center to Advance Palliative Care's (CAPC) analysis of data released in the 2007 American Hospital Association Annual Survey of Hospitals shows that 1,240 hospitals now provide palliative care programs. According to CAPC, the total in 2000 was 632.Subscribe Now for Access
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