The Palliative Medicine Consultation Service:

1
The Palliative Medicine Consultation Service

• Strengthening the Hospital-Hospice Connection

2
Objectives

• To describe usual processes in hospitals for
  chronically ill/terminally ill patients.
• To define strategies for improving the alignment
  of hospital and hospice services through the
  hospital-based palliative consultation
• To discuss the benefits to the medical staff,
  hospital, and hospice provided by the palliative
  care linkage
• To identify fiduciary responsibilities of
  hospital and hospice to identify and help
  navigate hospice patients into and through the
  hospital from the community.

3
Current Hospital Realities

• Care coordination among the various
  sub-specialists fragmented no quarterback
• Care communication among disparate family members
  fragmented
• Dying patients may outpace hospice referral
  processes within hospitals
• EDs rapidly cycle palliative patients to ICU or
  intermediate care
• Palliative Patients transition from ICUs late
  or die there

4
The Current Trajectory

• Chronically ill/terminally ill patient in crisis
  enters hospital via Emergency Department (ED)
• Frequently from area SNF and readmitted to
  hospital
• Often no family or surrogate accompanying them
• ED Rapid Cycle model results in front loaded
  testing and seeking a bed--- NOT on processing
  goals of care

5
Paradigm ED Patients Provided Life-Saving Effort

• Business model rapid throughput
• Failure to Treat Regulations
• ED physicians mediating between PCP at home and
  Hospitalist
• Hospitalist doesnt know patients history
• Many EDs dont look back
• Few Hospice referrals initiated in EDs
• YET, ED doctors and nurses describe gut level
  dissonance re palliative patients

6
The ICU

• (Varies with open vs closed unit)
• Average LOS palliative pts 7-14 days
• Average number of co-morbidities 5
• Average number of sub-specialists 5
• Each focusing on organ of specialty
• ( eg incremental change in Hgb )
• Yet ICU doctors and nurses describe gut level
  dissonance regarding palliative patients

7
The Hospital Usual Processes

• Chronically ill patients present with multiple
  co-morbidities
• Multiple co-morbidities multiple
  sub-specialists
• Little face-to-face case discussionmostly chart
  entry communication
• Patients/families expectations and education
  vary greatly
• Options such as LTACH not presented in tandem
  with Hospice
• Trach em peg em often mantra

8
Patient/ Family Expectations and Education Varied

• Family members disagreement with physicians end
  in stalemate, result in elongated hospital stays
• Agreements reached can be undermined by one
  physician or one family member
• Family members communication with multiple
  specialists is confounding for them
• Hospital staffs attempts to resolve may be
  lacking in objective clinical information or
  authority

9
Dying Patients Not Routinely Served by Hospice
During Hospitalization

• Not understood by many hospitalists or PCPs
• Transition to Hospice Benefit/care not norm
• Hospice considered option at discharge
• Considered late in disease and hospitalization
• Lack of understanding of hospice as HMO

10
Discharge to Hospice

• Patient/family experience it as abrupt
• Hospice described by physician or case manager
  accurately or not
• D/C Orders for Medications, treatments not
  congruent with Hospice POC
• Advance Directives, RS not available
• Patient/Family psychosocial issues from hospital
  not communicated routinely

11
How This Impacts Hospice

• Front-end intensity to catch up
• Patients unprepared or given unrealistic
  expectations
• Little/no advance care planning discussions
• Discharge Orders dont include Hospice formulary
  so must locate and initiate appropriate pain
  medications delays pain management
• Psychosocial assessment information often not
  sent or not relevant

12
Sparse Physician Education in Palliative
Medicine/Care

• Palliative/Hospice rotation not required for
  Residents
• Physician to Physician discussions inside
  hospital not readily available to community
  Hospice Medical Director
• Internal Education/Marketing efforts limited to
  periodic inservices for the already converted
  physicians

13
Strategies Needed from within

• What if there was an entity within the hospital
  --- to link hospital and hospice effectively ?

14
Strategies for Identification of Palliative
Patients

• Patients with exacerbation of chronic illness who
  choose palliative life-extending treatment
• Patients receiving disease-directed treatment who
  may benefit from palliation of sx arising from
  disease or treatment
• Patients with serious, life-limiting illnesses
  for whom hospitalization often segue into Hospice
• Patients with acute event such as CVA

15
Strategies Availability and Use of Palliative
Care Tools

• Standard admission orders and criteria
• Rounds Worksheet
• Indicators for Palliative/Hospice Referral
• Procedures e.g. Palliative Extubation
• Hospice-friendly Psychosocial/spiritual
  assessments completed in hospitals
• Educational materials
• Staff/Students/physicians
• Patient/family
• Data Base

16
Strategies

• Interdisciplinary Team Rounds, IDT Conferences
• Palliative Consultation 24 hours/7 days -
  palliative physicians, nurse practitioners with
  coordinating, mentoring roles
• Application of pain/symptom management protocols
• Institutionalization of ELNEC, EPEC training into
  hospital orientation
• Data collection, analysis, feedback

17
Strategy Coordination and Presence

• Presence/collaboration palliative professionals
  on hospital Ethics committees
• Queries to identify patients presenting in
  Emergency Department Are they currently in a
  Hospice? Would they be best served in Palliative
  Framework? Do they need Hospice now?
• Rounding routinely in ICU, IMCU
• Interface with Radiation Oncology, Interventional
  Radiology routinely
• Understand reimbursement and compliance
  ramifications of all involved providers

18
Strategy PMCs Role in Medical Education

• Teaching Fellows --- future physicians
• Exposing all residents to principles of
  Palliative Care
• Structuring practicum rotations
• Providing didactic Conferences
• Curbside mentoring of attending physician staff

19
Physician Education Impact on Hospice

• Physicians introduced to field of
  Palliative/Hospice medicine early
• Physicians more knowledgeable overall
• will more effectively interface with Hospice
• Hospice and palliative care become norms in
  medical education
• More available practitioners in the field to
  staff Hospice Medical Directorships

20
Hospital Platform Which Supports Palliative Care

• Patient status (prognosis and functionality)
  assessed on admission
• Pain and Symptoms measured numerically
• and effectively managed
• Discharge Planning initiated early
• Psychosocial Assessment provided by SW
• Family System Involvement
• University Health Systems Palliative Care
  Benchmark Field Book 2004 Unpublished

21
How Palliative Consultation Achieves Benchmarks

• Timing/frequency of rounding assessment
• Timing of post assessment intervention
• Timing of Palliative Intervention in ICU and
  Transfer
• Timing of ED Palliative Triage and Intervention
• Timing of Initial Advance Care Planning
  Assessment and follow-up discussions
• Extent to which Family is involved
• Valid, Reliable Measurement of Symptoms

22
How Palliative Consultation Helps Hospitals and
Hospices

• Palliative Consult
  Hospital/Hospice
• Service
• 
  

Care Coordination ACP Appropriate
Setting Discharge prep Physician, Staff Ed

Pain/sx mgt. P/F Satisfaction. Access to ICU
beds Less Diversion LOS MGT Physicians Awareness
23
Fiduciary Roles Hospice and Hospital in
identification of patients

• Hospital Query the patient routinely
• Look back process
• Notification of Involved Hospice
• Notification of non-coverage
• Hospice Notification of Patient sent to ED
• Accompany patient
• Work with Hospital Case Mgt

24
Day in Life of Palliative Medicine Consultant

• Arrive in the AM, gather team, and review status
  of patients on Palliative Care Unit (Palliative
  Care and Hospice patients)
• Print Palliative Medicine Consultation List
• See all new consults throughout hospital,
  including chart review, patient exam, family
  meeting and communication with attending
  physician
• Determination of goals of care and care plan
• Communicate same to all sub-specialists involved
  and write orders.

25
Day in Life of Palliative Medicine Consultant

• Participate in Pre-rounding reviews of
  pain/symptom and medication mgt over previous 24
  hours with pharmacy and others
• IDT rounds on PCU at established time
• Interface with ICU for complex patients,
  including de-escalation of treatments,
  benefits/burdens discussions, and goals of care
• Interface with ED for patients with chronic
  illness needing hospitalization and help
  facilitate direct admission to the APCU

26
Day in Life of Palliative Medicine Consultant

• Coordination with treating physicians, including
  radiation oncologist, medical oncologist,
  cardiologist, surgeons, etc.
• Coordinate continuum plan with physician assuming
  care outside the hospital, hospice physician, ECF
  physician or primary care physician

27
Day in Life of Palliative Medicine Consultant

• Review data with team, administration re
  clinical, utilization, financial, and patient
  satisfaction outcomes.