for Small Communities Lyn Ceronsky DNP, GNP, FPCN Director, - - PowerPoint PPT Presentation

Tailoring Palliative Care for Small Communities

Lyn Ceronsky DNP, GNP, FPCN Director, Fairview Palliative Care Palliative Care Leadership Center

Objectives

• 1. Identify the role of needs assessment and

community characteristics for planning palliative care

• 2. Describe common features of successful

models of palliative care in small communities

• 3. Discuss ways to develop your program to

meet quality standards for palliative care

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Why is Community-based Palliative Care Important Now?

* Aging population * Rising survival rates of person with debilitating chronic illness * High cost of care of patients with serious illness * Desire to be at home * Accountable Care Organizations * Medical Homes * Providers & health systems accepting risk New Models of Health Deliver Demand for Community- based Palliative Care Changing Demographics Economics of Health Care Patient Preferences of Health Care

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Key Characteristics of Community-based Palliative Care

C+b+P+C Model

Consistent Across Transitions

Services consistent across the many transitions expected with seriously ill patients: Philosophical transitions, disease-related transitions, locational & temporally dynamic transitions

Broadly Available

Services are available for people residing in community, with community defined as the summation of settings in which patients and loved ones live, work, play, and receive health care, both statically and during transitions.

Prognosis-independent

Services provided regardless of prognosis, diagnosis, or point along disease trajectory; not limited to payer-established prognostic thresholds or requirements of ongoing decline in functional status

Collaborative and coordinated

Delivered through multi-disciplinary team who provide regular multi-domain assessments & comprehensive plans, & with whom patient interacts with before, during & between transitions

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Complementary Principles

Design for Rural Health Care of the Future *

➔ Accessible ➔ Affordable ➔ Quality ➔ Community based ➔ Patient centered

Community-Based Palliative Characteristics

➔ Consistent across

transitions

➔ Across continuum ➔ Prognosis independent ➔ Collaborative and

coordinated

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What is a “Small” Hospital or Community?

➔ Critical access hospitals (25 beds or <) ➔ Small community hospitals (~100 beds +/-25

beds); may or may not have specialties (onc,surgery)

➔ Isolated hospitals ➔ Communities interested in building a palliative care

program across the continuum

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Growth of Palliative Care in Small Hospitals

22% of small hospitals (fewer than 50 beds) provide palliative care services

2011 National Palliative Care Research Center; data from AHA 2000-2009

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Challenges

➔Interdisciplinary team availability ➔Board certified providers—difficult to

find

➔“We do this already” ➔Characteristics of a rural setting ➔Reducing cost and LOS isn’t important ➔“We have a great hospice, so…..” ➔Lack of clinical/financial models to

replicate

➔How do we assure quality palliative

care?

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Rich Benefits of Rural/Small Communities

➔ Relationships ➔ Existing processes for care ➔ Community support and accountability ➔ Flexibility and opportunity to align with local

initiatives

➔ Preference of community members to

receive care in home community

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Successful Programs: Fertile Ground

➔Sufficient local health infrastructure ➔Having collaborative generalist practice and a

shared vision of change

➔Sense of local empowerment ➔Keys to success are working in a small

community, working together, and being community focused

11 Kelley 2011

Alliance of Community Health Plan Palliative Care Program Criteria

➔Critical Elements:

– Interdisciplinary team – Access – Symptom management – Communications with Care System and to patients/families – Documentation

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Steps in Program Development

➔ Needs assessment ➔ Develop operational and clinical model ➔ Education ➔ Measurement ➔ Financial ➔ Marketing ➔ Community partnerships ➔ Plan for growth

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What will we learn from a community assessment?

➔ Understand internal context (timing, patients,

geographic area, revenue sources)

➔ Stakeholders (identify and quantify others’ perceptions

and needs)

➔ Data: demographic, utilization, inventory providers and

payers

➔ Synthesize and identify service gaps and desired

• utcomes, patient population and organizational

readiness  next steps

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What problem(s) are addressed by palliative care?

➔ Use this question in your team discussions

– Treatments not concordant with individual’s goals – Late recognition of dying phase – Pain not managed as well as possible

➔ Rationale for needs assessment

– What has highest priority? – What do we have resources to address? – How can we start small and build?

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Case Study #1: Community of Elm Creek (early phase)

➔ Hospital quality leader facilitated Community

Needs Assessment

➔ Convened advisory group representing different

health care entities; lead by family physician and SNF nurse

➔ Identified two priority initiatives:

– Professional and community education – Care of patients with dementia

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Elm Creek Priority Initiatives

➔Education:

– Health fairs, patient brochures “Ask About” – Advance Directives – Professional communication education (on line)

➔Dementia:

– Choosing Wisely: feeding tubes, accelerate care – Goals of care discussion at transition points

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Case Study #2 Rural Midwest Health Care System

➔Population: Serve 40K, town 3000, 4 counties ➔Critical Access Hospital (CAH) 25 beds ➔Home care + hospice ➔Rural Health Clinic with 4 satellite clinics ➔Long Term Care (100 beds) ➔Clinical staff: family physicians, mental health

providers, some specialists

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Rural Midwest Health Care System

➔ Hospital, Senior services, home care, outpatient ➔ IDT, case management, telephonic support ➔ Staffing:

– RN case manager – Social worker – Pharmacist – Medical director, Family Medicine and HPM Board Certified – Mental Health Clinical Nurse Specialist – Spiritual volunteers from local faith communities

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Revenue Sources

➔Provider charges for usual face-to-face care

in clinic, hospital, LTC, or home

➔Insurance payer contract for unbillable visits

by nurse, social worker, spiritual care

➔Ability to demonstrate program capacity and

quality outcomes for contract discussions

➔Partnerships with VA system

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Case 3: Memorial Hospital and Clinic

➔APN-led, with collaboration from pharmacy,

social workers and chaplains

➔Patients seen in hospital and oncology clinic ➔Built on education of medical and nursing

staff

➔Evolved to include 2 affiliated hospitals

staffed with palliative care nurse

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Financial Sustainability

➔ Existing revenue sources (home care, home

visits)

➔ Contracts with payers (example: U-Care) ➔ Local philanthropy (+/-) ➔ Financial analysis supported by health system

focus; offset by other programs

➔ Partnership with community agencies ➔ Use of technology to extend clinical expertise

– Telephonic case management, telehealth

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Case Study #4: Minnesota Rural Palliative Care Initiative (MRPCI)

➔ Multiple communities convened over two years ➔ Began with needs assessment ➔ Primary strategies:

– Learning collaborative approach (IHI) – Use of domains of palliative care + NQF preferred practices – Focus on community capacity development – Small tests of change

➔ Multi-setting, multi-disciplinary teams ➔ Final Report:

– http://www.stratishealth.org/documents/PC_Stratis_Health_MRPCI_Final_Report_2011_06.pdf 25

MN Rural Palliative Care Initiative

➔Conceptual Framework: Community Capacity

Development Theory

➔18 month learning collaborative ➔Fairview Palliative Care + Stratis Health

(Medicare QIO)

➔10 communities, 9 K to 200K residents ➔Each team began with a needs assessment

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MN Rural Palliative Care Initiative

➔Interdisciplinary teams with members from

hospital, home care, nursing home, public health, clinics, hospice, community

➔Needs assessment ➔3 Learning Sessions and Outcomes

Congress

➔Small tests of change ➔Based on NQF Preferred Practices

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Application of NQF Preferred Practices

➔#3 – PC education to health care

professionals – 10 communities

➔#1 – Use of interdisciplinary

team – 5 communities

➔#10 – Educating patients to make informed

decisions – 4 communities

➔#12 – Use of scales to measure

symptoms – 4 communities

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MN Rural Palliative Care Initiative

➔Outcomes:

– Increased knowledge of symptom management and goals of care discussions – 6/10 communities offering interdisciplinary palliative care services – Others developed/improved processes for ACP, common order sets to improve transitions, education to clinicians and community members

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Quality Measures: Is it possible?

➔Pilot study with 5 rural Minnesota

communities to assess feasibility of collecting

• perational, clinical, satisfaction and

utilization data

➔Provided feedback on gaps in clinical

assessment

➔Demonstrated modest impact on utilization

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What do these have in common?

➔ Specialized clinicians may be hard to find; need

to build on existing and overlapping skill sets

➔ Strong community support and investment ➔ Know patients and families as neighbors ➔ Are all unique ➔ Demonstrate flexibility and resourcefulness

every day

➔ Want to give great care to patients

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Characteristics of Successful Programs

➔ Began with a needs assessment, altered plans ➔ Built on local talent and expertise including faith

communities, community health workers, Area on Aging

➔ Focused on primary palliative care: education and

process improvement

➔ Measured, marketed, motivated ➔ Connected palliative care to other initiatives – Example: Alzheimer's

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Strategies for Success

➔Administrative buy-in and alignment with

mission

➔Dedicated team leadership ➔Education ➔Standardization of processes, clinical tools ➔Domains of palliative care and NQF

Preferred Processes

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Supporting Processes

➔Advance Care Planning ➔POLST/MOLST ➔EMRs and templates to prompt

identification of prognosis, triggers for family meetings, document patient goals

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Summary

➔Start with a needs assessment and build ➔Examples of palliative care programs do exist ➔Palliative care + Quality improvement ➔State coalitions (CA, NY, MN, WI) ➔Be mindful of financial and clinical

considerations…which are changing

– ACO total cost of care, Medical Homes, Decrease in silos of care, interdisciplinary teams

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References and Resources

Alliance of Community Health Plans: Health Plans, Palliative Care Blueprint. Alliance of Community Health Plans, 2010. Cassel, J.B., Webb-Wright, J., Holmes, J., Lyckholm, L. Smith, T.J. (2010) Clinical and financial impact of a palliative care program at a small rural hospital. Journal of Palliative Medicine, 13(11), 1339-1343. Ceronsky, L., Grangarrd Johnson, L., Weng, K. “in press” Quality measures for community-based, rural palliative care programs in Minnesota: A pilot study. Journal of Palliative Medicine. Kamal, Curro, Ritchie C, Bull, Abernathy. (2013). Community –based palliative care: the natural evolution for palliative care in the U.S. Journal of Pain and Symptom Management,46 (2), Kelley, M. L., Williams, A., DeMiglio, L., & Mettam. H. (2011). Developing rural palliative care: validating a conceptual model. Rural and Remote Health, 11 (online) ttp://www.rrh.org.au McGrath LS, Foote DG, Frith KH, et al.: Cost effectiveness of a palliative care program in a rural community hospital. Nurs Econ 2013;31:176–183. Minnesota Rural Palliative Care Initiative, www.stratishealth.org/news/20110803.html

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Questions and Comments

➔Do you have questions for the presenter? ➔Click the hand-raise icon on your control

panel to ask a question out loud, or type your question into the chat box.

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CAPC Events and Webinar Recording

➔ For a calendar of CAPC events, including upcoming

webinars and office hours, visit

– https://www.capc.org/providers/webinars-and-virtual-office- hours/

➔ Today’s webinar recording can be found in CAPC

Central under ‘Webinars: Community-Based Palliative Care’ – https://central.capc.org/eco_player.php?id=186

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