Palliative Care In Action Bridging Gaps in Care

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Palliative Care In Action Bridging Gaps in Care

• Martha L. Twaddle MD, FACP
• Medical Director, PCCHNS
• Assistant Professor of Medicine
• Director of Palliative Care
• Rush Medical College
• Evanston - Northwestern University School of
  Medicine
• President, The American Academy of Hospice and
  Palliative Medicine

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• Center to Advance Palliative Care
• Mount Sinai School of Medicine
• 1255 5th Avenue, C-2
• New York, NY 10029
• 212-201-2670 office
• 212-426-1369 fax
• 212-201-2680 event line
• www.capcmssm.org

A national initiative supported by The Robert
Wood Johnson Foundation at the Mount Sinai School
of Medicine.
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Case Study - Rose

• Consult called by Internist big picture needs
• I hope we can keep her alive
• Refractory pneumonia, myelodysplasia
• Provided significant psychosocial support
• Patient articulate of illness and sense of
  prognosis, 92 yo husband NOT!

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Palliative Care
Modern Medicine
Hospice
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Case Study - Rose

• Palliative Care Service
• Consultation Team
• Followed Rose for several days while receiving
  continued disease modifying treatments
• Much time spent with family clarifying and
  supporting goals of care.

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Palliative Care Consult

• Reimbursements
• MDs of same specialty can see a patient on the
  same day if they link their charges to different
  diagnoses
• Primary MD ? Primary Diagnosis
• Consultant in Palliative Care ? Symptoms

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Palliative Care Consult Team

• How do we learn?
• Post-graduate MDs traditionally learn practical
  knowledge through consultation
• How do we facilitate communication?
• Consultation provides give and take
• Forges relationships and networking
• How do we build support?
• For patients families
• For the professional caregivers
• MDs, RNs and other staff

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Palliative Care Consult Team

• Additional goals
• Education disseminating information
• Diffusing tensions and intensity
• The blessing of the second opinion
• Spreading the support for patients and families
• Supporting the professional caregivers
• Affirming the Art of Caring

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Giving Shape to the Opportunities

• Palliative Care Service
• Consultation Team
• Inpatient Unit
• Hospice Unit
• Palliative Care Unit
• combo
• Scatter Beds

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Admission to Inpatient Hospice

• Admission
• Physician ? Palliative consultation
• Like the Rehab model
• From hospital, home or nursing home
• Discharge/readmit - nonDRG
• Relatively short ALOS

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Scatter Beds

• Much more challenging given the variable of
  nursing support
• Multiple contractual relationships
• Direct admissions within hospital
• Discharge/readmit for Hospice GIP
• Team-oriented care
• Enhancement of care in familiar setting

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Case Study - Rose

• Transferred to the Hospice IPU
• The Intensive Caring Unit
• Aggressive Palliative Care (beyond scope of other
  setting)
• Intensive End-of-Life Care
• Stabilization
• Transition to another site of care

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Relationships with Physicians

• Consult Model is key
• Think the Rehab model
• Collaboration and support
• Enhancing their care of their patient
• Enlarging the circle of support not replacing
  but expanding the concept of team!

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Role of Medical Director

• Hospice Med Directors should be Consultants in
  Palliative Medicine
• Educators in the field
• Intensivists in End-of-Life Care
• Liaison with Interdisciplinary team

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Integrating the Interdisciplinary Team

• Consult Model
• Formal Team discussion of cases before or after
  consult
• Quarterly meetings with Hospital Administration
  Team
• Minutes
• Action plans
• Quality Assurance

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Impact on the Culture of the Hospital

• Hospice and Palliative Care are not soft
  alternatives or a consolation prize!
• Enhanced understanding of Hospice Palliative
  Care
• Affirmation of professional caring
• Diffusing stress
• Support for families and professionals
• Enhanced Wellness

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Impact on Patient Care

• Best Practices
• Outcomes
• Pain and Symptom Control
• Average Initial VAS at consultation 7
• 24 hour follow-up 2
• Cost appropriate utilization

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Continuum of Services

• Any Stage
• HomeCare
• Community Outreach
• Mobile Medical Unit
• Personal Care Assistance
• Palliative Care Consult Program

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Case Study - Barbara

• Followed for over 2 years in Ambulatory setting
• Very clear of goals of care
• Unexpected decline during and after XRT
• Admitted to Home Care
• Transitioned to Medical Home Visits

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Case Study - Barbara

• Improved seen as MD home visit
• Declined again admitted to Hospice InPatient
  Unit
• Home briefly with Hospice Home Services
• Re-admitted to IPU and died approximately 10 days
  later

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Advantages to Continuum

• Brings Services to the Community Level
• Provides services in the right setting
• Meets Patient Needs
• Increases Patient Choice
• Increases Patient/Family Satisfaction