Supportive Voice Vol. 10 No. 2 Spring 2004
by Mary Ann Gill
Ms. Gill is Executive Director, Mount Carmel Health System Palliative Care Service, Columbus, OH.
Mount Carmel is one of six Palliative Care Leadership Centers that have been selected and funded by the Robert Wood Johnson Foundation to assist in the development of palliative care services nationwide.
In 1995 Mount Carmel Hospice, in Columbus, OH, proposed to its parent hospital system a culture-changing project—a hospital-based palliative care program. Today, Mount Carmel has a centrally administered, hospital-based palliative care service that has served approximately 7,500 patients since its beginning in 1997.
Mount Carmel's hospital-based Acute Palliative Care Service consists of a consultation service and three Acute Palliative Care Units (one in each of the Mount Carmel Hospitals), staffed by an interdisciplinary team of professionals competent to provide direct care to patients and their families. The Acute Palliative Care Service and the preexisting hospice program comprise the continuum of palliative care at Mount Carmel. Mount Carmel Health System is a member of Trinity Health, based in Farmington Hills, MI.
From Educated Guesses to Validity
Many of the first-wave palliative care programs, whose pioneering efforts were based on what seemed intuitively the right thing to do, had, in starting their programs, little actual supporting evidence other than standard business planning and hospital utilization statistics. Many of the early programs were, like Mount Carmel, committed to validating their work through data collection and outcome analysis. Today these programs have the data to prove the positive impact of palliative care. So, as more hospitals and hospices become interested in developing palliative care services, they have access to validated tools, the experience of established programs, and a body of knowledge concerning the creation of the infrastructure of such programs.
Today, we also know more about:
The Demographics
We know far more today about the potential users of palliative care. For example, the U.S. Department of Health and Human Services's Agency for Healthcare Research and Quality (AHRQ) issued a report stating that from 80 percent to 85 percent of deaths in the United States are among elderly Medicare patients "who die from chronic conditions such as heart disease, cerebrovascular disease, chronic obstructive pulmonary disease, diabetes, Alzheimer's disease and renal failure." (1) This group is predicted to double in size by 2030. These are patients needing palliative care services.
The Disease Trajectory
We know more about what the courses of those chronic diseases look like. According to the AHRQ report, and congruent with our experience, the trajectory of these diseases is slow, marked by repeated sudden severe episodes of illness requiring hospitalization. And the hospitalizations are needed, not to cure the disease but to medically intervene to reestablish stability. Yet patients sometimes die during these crises. Hospitals are challenged "because there is often no clearly recognizable threshold between being very ill and actually dying." (2) This is where palliative care has a major role.
Effective and Efficient Symptom Management
We can now prove that care coordination and rapid focus on symptom management results in symptom abatement and high satisfaction levels for patients with advanced diseases—and that this takes fewer hospital days. At Mount Carmel, for example, a rounds worksheet is used to measure data as care is provided. The resulting data collection and analysis heightens credibility and confidence levels for those entering the field today.
What Patients Want
Surveys by AHQR, the National Hospice and Palliative Care Organization, and others reveal that chronically ill elderly patients want and value discussions about realistic and achievable clinical outcomes. Work done by programs, such as Respecting Choices and the CALL Care program, teach professionals to facilitate advance care planning discussions in the community. For patients in the hospital, the palliative care team can function as the translator of their wishes.
The Financial Impact of Palliative Care
We know that efficient symptom management results in earlier hospital discharge and that length of stay (LOS) can be a substitute indicator for hospital costs. We know, too, that advance care planning discussions result in heightened awareness of options and help prepare patients for reentering palliative care at the next crisis—this is another way LOS is reduced. And we know that reduced hospital LOS opens up much-needed ICU beds for other patients who need care, which results in new hospital revenue. (At Mount Carmel, we experience cost reductions between $1.8 million and $2 million per year). Earlier transition to hospice has a positive impact on hospice LOS and quality of care. Hospitals need this data-driven reassurance to manage the high volumes of patients that will be admitted in increasing numbers in the future.
Defining Palliative Care
Over time, many definitions of palliative care have been articulated. We have found that it is helpful to use the term "palliative care" with a modifier, such as "hospice palliative care," "hospital-based (or acute) palliative care," "ambulatory (or outpatient) palliative care," "residential (or long-term) palliative care," "community case management palliative care" (as in the CALL Care program). These modifiers refer to the setting in which palliative care is primarily provided, but other important differentiators are program scope and mission, role of the interdisciplinary team, disease management focus, source of reimbursement, and relative predictability of the prognosis. A new program can, by defining the type of palliative care it intends to provide, better focus on the time and resources such care will require. It is essential that referring clinicians understand these definitions.
Getting the Message to the People
In order to communicate to health care organizations what is now seen as a valid body of information, one that can help them navigate the implementation process more easily, the Robert Wood Johnson (RWJ) Foundation has funded six Palliative Care Leadership Centers (PCLCs) that, over the next two and a half years, will hold site-visit learning experiences for teams of "learners" from health care systems. Mount Carmel originally proposed the PCLC concept to the RWJ Foundation a few years ago, when hospitals and hospices were seeking site-visit training from an already very busy Mount Carmel Palliative Care Team. The RWJ Foundation carefully considered the concept, eventually asking the Center to Advance Palliative Care in New York City to lead, oversee, and coordinate the project. After issuing a request for proposals, the foundation ultimately funded six programs.
How the PCLC Works
Mount Carmel's first site-visit teams consisted of (at a minimum) a clinical leader, finance professional, physician, and a representative of the local hospice. Teams developed strategies for their own organization and left the site with specific work plans. Each team will receive distance mentoring for one year after its visit. Each took home all the tools needed to implement a program. Each PCLC must successfully initiate 100 new programs. We hypothesized that, through programs like the PCLC initiative, the guesswork will be taken out of palliative care development and palliative care will soon be a part of most health care systems.
--------------------------------------------------------------------------------
(1)B. Kass-Bartelmes and R. Hughes, "Advance Care Planning: Preferences for Care at the End of Life," Research in Action, March 2003, p. 3.
(2) Kass-Bartelmes and Hughes.
The Six PCLCS
Fairview Health Services, Minneapolis
Massey Cancer Center of Virginia Commonwealth University, Richmond, VA
Medical College of Wisconsin, Milwaukee
Mount Carmel Health System Palliative Care Service, Columbus, OH
Palliative Care Center of the Bluegrass, Lexington, KY
University of California, San Francisco
For more information, or to register for a site visit. go to www.capc.org/pclc.