The Power of the Few

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The Power of the Few

• Description of a New Outpatient Palliative Care
  Program in a Tertiary Cancer Centre

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Introduction

• 50 of patients diagnosed with cancer will
  eventually die of their cancer
• gt80 of Cancer patients will experience pain and
  symptoms that increase as death approaches
• Oncology care today occurs primarily in
  ambulatory care settings
• Ambulatory Palliative Care Clinics represent an
  opportunity to further the goals of the modern
  palliative care movement by delivering care
  earlier in the disease course
• Outpatient Clinics have been found to improve
  patients symptoms and high levels of patient
  satisfaction

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Juravinski Cancer CenterHamilton, Ontario

• Multidisciplinary Outpatient Cancer Center
• Medical, Radiation, Surgical Oncology
• 8000 new patients per year
• 18000 patients per year

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Palliative Care Team Who Are We?

• 0.5 FTE Palliative Care Physician was hired in
  2006
• Two full time Advanced Practice Nurses (APN) were
  reassigned to the new Palliative Care Service
• Part of the Supportive Care Department which also
  included fulltime staff in nutrition, social work
  , and mental health
• Located in shared clinical space with the
  medical, radiation and surgical oncologists

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Palliative Care Team Who We See?

• Adult cancer patients are referred by their
  medical, radiation or surgical oncology team
  (physician, nurse social worker)
• Patients have a cancer diagnosis and a life
  expectancy of one year or less as determined by
  an experienced palliative care physician
• Patients are triaged by APN to determine level of
  acuity
• Time from referral to initial appointment varies
  from same day to 2 weeks based on acuity
• Appointments are often scheduled on the same day
  as their oncology appointments

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Palliative Care Team What We Do?

• 4 half day palliative care clinics
• All patient visits include assessment by the
  physician and APN
• Initial visits are 1 hour and follow-up are 40
  minutes
• Patients complete the Edmonton Symptom Assessment
  Scale (ESAS) at the initial visit and at each
  subsequent visit
• Initial visits include complete chart review,
  medical and psychosocial history and physical
  exam
• Care includes palliative treatments, education,
  counselling, and referrals to other disciplines
  (social work, pharmacy, nutrition, chaplain,
  radiation oncology, anaesthesia, neurology and
  psychiatry) as needed

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Palliative Care Team What We Do?

• Patients are routinely contacted by the APN
  within one week after their initial visit
• Follow-up appointments are scheduled depending on
  acuity of need as determined by the physician and
  vary between days to months
• Patients are encouraged to contact the team prior
  to their follow-up appointments should they have
  unmet needs
• Flexibility to respond to patients and families
  needs is maintained through phone calls and same
  or next day clinic visits

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Palliative Care Team Models of Care

• Consultative support to some patients and their
  physicians
• Comprehensive services using a shared care model
  with oncologists or family practitioners for
  other patients
• Communication with JCC team and primary
  practitioners occurs through
• the availability of the electronic patient
  records to all JCC team members
• e-mails
• telephone calls
• in-person discussions
• initial consults and progress notes are sent to
  their primary care practitioner

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Methodology

• Retrospective chart reviewed to document care
  provided from February 2006 through to the end of
  August 2006 including the following
• socio-demographic information,
• number of visits and telephone calls with members
  of the palliative care team
• diagnosis
• clinical complications
• Information about admission to acute care was
  gathered via the electronic record and hospitals
  discharge summary

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Sampling Method

• 122 patients were referred to the Ambulatory
  Palliative Care Team from February 2006 and June
  2006
• Of these 49 were not seen by the physician and
  were excluded from the study
• 27 failed to attend booked appointment secondary
  to death, hospitalization or patient choice
• 22 were non palliative but who had pain and
  symptom issues and were seen by the APNs
• Physician saw 73 patients over the 5 month study
  period

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Sample

• Mean age of 50.9 years
• 52 were female
• 68.5 married
• Site of Primary Cancer Diagnosis
• Breast n13
• Lung n10
• Pancreatic n7
• Esophageal n6
• Large variation of other primary sites

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Program Activity
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Program Activity

• Average length of follow-up for all patients was
  100 days
• 32 (44) patients died, average length of
  follow-up was 66 days (range 4-155 days)
• Average length of follow-up for those who
  survived was 122.5 days (range 63-206)

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Place of Death
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Place of Death

• Ambulatory Palliative Care Program
• Home 13 (41)
• Acute Care Hospital 12 (37)
• Hospice/Palliative Care Facility 7 (22)
• Provincial Averages
• Home (15)
• Acute Care (52)
• Other Long term Care and Unknown (33)

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Use Acute Care Services

• 25 (34) of patients seen in the Ambulatory
  Palliative Care Clinic subsequently used Acute
  Care Services
• Emergency Room (n7)
• 5 were seen only once
• 1 was seen 3 times with the last encounter a
  terminal event
• 1 was seen in ER and then at a later date
  admitted to hospital, dying 8 days after
  admission
• Admission to Hospital (n18)
• 9 had a single admission (8 were discharged and 1
  died)
• 5 had 2 admissions
• 3 had ER Visits after discharge from hospital
• 1 had multiple admissions

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What Is New?

• We are seeing an increase in the number and type
  of primary cancer diagnosis of referrals
• We have hired a new fulltime primary nurse
• We are beginning to participate in clinical
  research
• Strong Links with the newly opened Tertiary Acute
  Palliative Care Inpatient Unit and Bob Kemp
  Hospice
• A new article in this months Journal of
  Palliative Medicine

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2008 DATA

• 120 referrals in 3 months vs. 5 months in 06
• 64 seen by MD vs. 73 in 2006
• 2-5 months follow up 20 deaths (31) vs. 32
  deaths in 2006
• 7 deaths in hospital (35) in 06 7 deaths in
  hospital

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Benefits of Outpatient Palliative Care

• Meier D., Beresford L.
• Journal of Palliative Medicine
• Vol. 11, number 6, 2008

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Benefits of Outpatient Patient Palliative Care

• Meets palliative care needs of community dwelling
  patients with serious illness
• Can raise awareness and model the practice and
  benefits of palliative care
• Follow up and continuity for palliative patients
  discharged from hospital
• Resource for patients to call
• Improved management of disease
• Time for deeper pt/family understanding

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Benefits of Outpatient Patient Palliative Care

• Continuity of care across settings
• palliative providers to work with patients
  earlier, less crisis, more relationship
• Setting for professional education, training and
  research
• Potential to save the health system money by
  managing transitions and preventing
  rehospitalizations

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Challenges of Outpatient Palliative Care

• Staffing/space/ logistical support
• Unpredictable demand
• Identity question ( ?chronic pain service)
• Communication infra-structure with primary staff,
  incompatible information systems
• Communicating role and value to administrators
  and referral sources

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UCSF Outpatient Program

• Co-management model
• Referrals from outpatient departments of cancer
  center
• 4 ½ day clinics
• 3 MDs, other staff shared
• Scheduled clinics and phone support
• Symptoms and advanced care planning

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Dartmouth Hitchcock Outpatient Service

• Clinic runs Mon- Fri. 9- 5
• In the cancer center
• 2 APNS and SW see all patients
• Chaplain and palliative MDs as needed
• Team will travel to other clinical settings
• 1233 referral sin 2007
• Automatic referrals for stage IIIB and IV lung
  ca, pancreatic ca, and GBM

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University of Alabama Outpatient Clinic

• Supportive care/ palliative care/ cachexia HIV
  clinics
• Each ½ day/week
• Nurse coordinator, nutritionist, SW and
  psychologist

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Fairview Health System in Minneapolis

• 1 day/week 2 MDs alternate or a NP and full
  time SW
• Share space and infrastructure with outpatient
  pain clinic
• referrals from inpatient

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MD AndersonOutpatient Clinic 2007

• Wait time 1 -2 days
• Clinic visit approx. 3hrs
• 704 new patients 2007
• Avg. 3 follow up visits
• 2543 follow up visits

• Wait time 1-2 weeks
• Clinic visits ? 1- 2 hours
• 400 new patients 2007
• Avg. 3 follow up visits
• 1618 follow up visits

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Oupatient Clinic

• 20 clinics/ week vs 4 clinics/week
• 8 rooms vs 2 rooms
• 704 patients vs 400 patients
• 2543 flups vs 1618 flups
• 20 of the resources seeing 60 volume

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Discussion

• At our centre we were able to create an
  outpatient care clinic without a large donation
  or allocation of resources
• Small number of interested individuals, some
  administrative support, and some creative
  thinking, such clinics could be expected to
  immediately improve patient and family
  satisfaction, decrease the use of acute care
  services and in-hospital deaths, and optimize
  delivery of limited health care resources

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Questions ????