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Case managers are in a good position to recognize patients who have serious medical problems that are causing them and their family members stress, and refer them for a palliative care consultation, experts say.
As they coordinate care for complex and seriously ill patients, hospital case managers can take a key role in identifying patients who may benefit from palliative care and referring them for a palliative care consultation, says R. Sean Morrison, MD, director of the National Palliative Care Research Center and professor of geriatrics and palliative medicine at Icahn School of Medicine at Mount Sinai in New York City.
Palliative care is a relatively new medical team that focuses on improving the quality of life for patients with serious illness, Morrison says. “Palliative care provides an added layer of support for patients by identifying and treating distressing symptoms, helping the patient and family articulate their goals for medical treatment, and working to match the treatment patients receive to those goals,” he says.
Palliative care can benefit patients with serious illnesses at any stage, and should be considered for any patients who frequently are in and out of the hospital, says Joseph D. Rotella, MD, MBA, HMDC, FAAHPM, chief medical officer of the American Academy of Hospice and Palliative Medicine.
“When patients have serious medical problems, whether near the end of life or not, they suffer a lot of related symptoms and stress and so does their family. When we address this suffering while treating their medical problems, patients do much better,” Rotella says.
In addition to controlling pain and other physical symptoms, palliative care relieves depression and anxiety and provides support and spiritual help for the family and other caregivers as well as the patient, Rotella says.
“When patients have an illness that is having an impact on their lives and causing them and their family members to suffer, case managers should think about palliative care and ask for a consultation from the palliative team,” Rotella adds
Palliative care is provided in conjunction with medical treatment, adds Linda Sallee, RN, MS, CMAC, ACM, IQCI, director for Huron Healthcare, headquartered in Chicago.
When patients are admitted to the hospital, the treatment team’s goal is to diagnose them, treat them, and discharge them. The team is concerned with getting the patient past the crisis, focusing on meeting the needs of the whole person, Sallee adds.
“Palliative care providers look at the patient from a broader perspective and focus on treating symptoms that may not go away as well as providing the emotional support that patients and family members need,” Sallee adds.
Case managers can play a valuable role in ensuring that the care patients receive from all providers is coordinated and that the primary treatment team and the palliative care team know what the other team is doing, Rotella says.
“When patients are receiving care from specialists, such as an infectious disease team or an oncology team, and a palliative care team, someone needs to bring all of the medical care into alignment. Case managers have the skills to coordinate with all of the clinicians and can be invaluable in making sure everybody is on the same page,” Rotella says.
Makeup of the palliative care team varies by hospital, Rotella points out. A medical specialist, a nurse who also acts as a case manager, a social worker, and a spiritual counselor typically make up the core team.
At Montefiore Health System, the palliative care team includes an art therapist and a music therapist in addition to the core team, says Peter Selwyn, MD, MPH, director of the palliative care program and chair of the Department of Family and Social Medicine at Montefiore Health System in Bronx, NY.
At Mount Sinai, the teams include palliative care social workers, who are specialists knowledgeable about community resources for complex patients and assist the case managers on the floor with discharge planning, Morrison says.
“The palliative care population represents less than 10% of the average case manager’s caseload, which means that 90% of the patients case managers deal with every day are not seriously ill with complex needs. Patients with palliative care needs make up 100% of the caseload of the palliative care social workers. Like the rest of the palliative care team, they are an added layer of support for patients and families,” he says.
Hospice and palliative care are not interchangeable terms, Selwyn points out. “Patients eligible for hospice services need to have an estimated prognosis of less than six months. There is no such strict eligibility criteria for palliative care. Patients with chronic progressive illness, with loss of function, pain, or other symptoms or otherwise suffering from serious illness, may all benefit from palliative care along with their families and caregivers,” he says.
Patients don’t have to give up disease-specific therapy in order to receive palliative care, Selwyn adds. “The palliative care team focuses on improving the quality of life for patients and their families, providing comfort and support in conjunction with any ongoing disease-specific care that may be offered, depending on the patient- and family-defined goals of care. Our goal is to help people have the best quality of life they can when they are dealing with serious medical problems,” he says.
Hospice services are a subset of palliative care, Rotella says. “Palliative care providers address the emotional, physical, spiritual, and social needs people have whether they have a serious illness they will have to live with for years, or are facing the last days of life,” he says.
“When people get near the end of life and are eligible for hospice, the focus is usually primarily on palliative care and comfort. They may receive treatments for their underlying medical problems if they will improve the quality of life, but the focus is not on a cure,” he says.
Palliative care helps control pain, shortness of breath, and physical symptoms for patients in addition to relieving depression and anxiety and providing spiritual help for patients and family members. It also provides assistance for psychosocial needs such as help with financial issues or identifying community resources, Rotella says.
The inpatient treatment team concentrates on managing the acute problem for which the patient was admitted while the palliative care team helps the patient cope with the effects of the illness and its treatment, including pain, anxiety, and other symptoms. “We help with whatever problems matter to the patient, including financial issues and assisting with practical resources,” Rotella says.
In some hospitals, palliative care goes under a different name such as comfort care or the supportive care team. “People may confuse hospice and palliative care. We don’t want people to be afraid to receive palliative care at any point in a serious illness because they mistakenly think it is only when they are nearing the end of life,” Rotella says.
Financial Disclosure: Managing Editor Jill Drachenberg, Associate Managing Editor Dana Spector, and Editor Mary Booth Thomas, report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Nurse Planner Toni Cesta, PhD, RN, FAAN, Consulting Editor of Hospital Case Management, is a consultant with Case Management Concepts LLC.