Ohio health care system is palliative care leader

Hospices can go through training program

Mount Carmel Health System in Columbus, OH, was one of the first health systems to recognize the national need for having palliative care integrated into the health care for heart failure and other patients.

"Mount Carmel proposed the palliative care leadership concept to Robert Wood Johnson Foundation [of Princeton, NJ]," says Mary Ann Gill, RN, MA, executive director of palliative care services at Mount Carmel. Mount Carmel Health System Palliative Care Service is one of the Center to Advance Palliative Care (CAPC)-designated Palliative Care Leadership Centers. Mount Carmel Health System has three acute care hospitals with a total of 1,048 beds, a college of nursing, a residency program, a home health agency, a hospice, and other services.

The Mount Carmel Health System Palliative Care Service includes three hospital-based palliative care programs.

"We started in 1997 with the palliative care process," Gill says.

The health system's palliative care program worked so well that other health systems took notice. Palliative care officials received many requests from other health care systems that wanted to see their model up close, but they were so busy keeping up with palliative care patients that they couldn't provide mentoring services to other organizations, Gill notes.

"So we proposed a concept of mentoring and having financial support from grants to do that, and eventually we created the concept of the leadership center," Gill explains. "So far we have trained 102 programs from 37 states over a three-year-period that will end in July, 2006."

www.capc.org.

Palliative Care Leadership Centers, including Mount Carmel's, provide a two-day training session that exposes attendees to all aspects of building a successful palliative care program. The centers also offer one year of mentoring services after the training has been completed.

There are six Palliative Care Leadership Centers, which provide training and mentoring services to other health care professionals.

The cost is $1,750 per team, which includes up to four people, from an institution, or $1,500 per team, if one of the four people includes a hospital finance person.

Palliative care and hospices are natural partners in the care of patients with chronic illnesses.

For example, hospice and palliative care staff should be prepared to teach families how to deal with a patient's symptom exacerbation, says Sharol Herr, BSN, MSEd, RN, CHPN, palliative care nurse clinician and educator at Mount Carmel Health System Palliative Care of Columbus, OH.

Mount Carmel Health System cares for many patients with chronic diseases, Gill says.

"They enter first through the emergency room and use a lot of hospital resources, often spending more time in the hospital than what the hospital is paid to serve them," Gill says.

With a palliative care program, a health system can train patients and families to improve their chronic disease management, and it can prepare them for the possibility of hospice care, Gill explains.

While it might appear that hospital systems could provide this training and preparation without having a palliative care program, it typically does not happen, Herr notes.

"You would expect there would be discussions about patients and their wishes in terms of their advanced disease process and how they're not going to recover from it," Herr says.

But this doesn't always happen in acute care hospitals, Herr says.

Palliative care and hospice programs have an expertise in end-of-life and advanced disease management that sometimes is lacking in other hospital environments, Herr adds.

Palliative care staff, like hospice staff, are comfortable initiating patient discussions about advance directives and care planning and asking questions about resuscitation and the burdens of treatment, Herr explains.

"That's not something typically done in the acute care world to the same degree," Herr says.

For example, the palliative care team is well trained in working with heart failure patients.

"One thing we do is evaluate patients who have heart failure," Herr says. "When heart failure patients start to return to the hospital frequently, requiring acute care, then that tells us we need to be looking at the plan that's in place for them, and we also need a continuum of care."

Patients with heart failure might require a higher level of vigilance and interaction between the hospice staff and the cardiologist or physician, Herr adds.

"The patient will need closer monitoring to prevent exacerbation of symptoms," Herr says.

Palliative care staff and hospice staff also should be prepared to teach patients about self-monitoring, even if they already have received some instruction, Gill says.

"Patients who have heart disease are fairly accustomed to doing self-monitoring, but they may not do it well," Gill says.

Sometimes the instructions patients might receive in the acute care hospital are not as appropriate for the hospice care program, Gill notes.

"For example, when patients leave the hospital, the hospitals are held accountable for specific discharge instructions for these patients, including things like weight monitoring, follow-up appointments, medications taken on certain diets, activity levels, and smoking cessation, and what to do if symptoms worsen," Gill explains. "But smoking cessation for a patient in a hospice program probably won't be as much of a priority."

One thing both palliative care and hospice care do is consider the patient's perspective, choices, and priorities.

"Maybe the person only has a short amount of time left and he wants to smoke," Gill says. "You have to think about it from their point of view."

There are benefits to a hospice when a parent health system forms a palliative care program, Gill says.

"I personally think that the concept of partnering and creating a link to the hospital will do nothing but enhance the hospice's ability to be a part of the mainstream health care in a different way than we have been in the past," Gill says.

"We've found that hospitals are very unaware of the complexity of hospice work in the community, and the hospices are not always aware of the complexity of chronic diseases and how chronic diseases burden the resources of a hospital," Gill says. "Together these entities can actually benefit both sides of that continuum."

Also, palliative care physicians in a hospital will partner with other physicians and be able to explain to their colleagues why it might appropriate for a particular patient to be referred to hospice care, Herr says.

"The other piece is that the palliative care physicians are able to have difficult discussions with patients and families, so they share the weight of transitioning this patient to hospice care," Herr adds.

Need More Information?

  • Janet Carroll, MSN, CHPN, Vice President of Clinical Services, Hospice of Lancaster County, 685 Good Drive, P.O. Box 4125, Lancaster, PA 17604-4125.