Program From the Inside Out Patsy Astarita, LCSW-C, OSW-C Michelle - PowerPoint PPT Presentation

Building a Palliative Care Program From the Inside Out Patsy Astarita, LCSW-C, OSW-C Michelle Abramowski, CRNP 1

Driving Factors  Population Health  Cost of Oncology Care  Choosing Wisely (ASCO & ASTRO)  Better qualityof life at EOL (Temel, 2010)  Standard of Care — NCCN, ASCO, CoC 2 University of Maryland Upper Chesapeake Health

Population Health in Oncology University of Maryland Upper Chesapeake Health 3

Studies Listed  Glare, P.A., et al. (2011). Palliative Care in the Outpatient Oncology Setting: Evaluation of a Practical Set of Referral Criteria. Journal of Oncology Practice, 7(6) , 366-370.  May, P., et al. (2015). Prospective Cohort Study of Hospital Palliative Care Teams For Inpatients with Advanced Cancer: Earlier Consultation Is Associated With Larger Cost-Saving Effect. Journal of Clinical Oncology, 33 , 1-8.  Temel, J.S., et al. (2010). Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer. New England Journal of Medicine, 363(8) , 733-742. University of Maryland Upper Chesapeake Health 4

Choosing Wisely ASTRO Recommendations ASCO Recommendations Don’t use therapy for: Don’t routinely:  Solid tumor pts with low  Use extended ECOG fractionation schemes (>10 fractions) for  No benefit from prior palliation of bone interventions metastasis  Not eligible for clinical trial  Use non-curative therapy  No strong evidence without defining goals of supporting clinical value treatment and considering palliative care referral University of Maryland Upper Chesapeake Health University of Maryland Upper Chesapeake Health 5

Challenges Identified within KCC  Inadequate communication between department/treatment teams  Lack of education related to PC or EOL  No budget, use existing resources  Lack of documentation/ data mgmt on Advance Directives  Hospital PC team focused on ICU  Focus of CLN team was on newly diagnosed patients, not on PC or EOL care  Reactive versus proactive use of resources 6 University of Maryland Upper Chesapeake Health

Starting Point  In-patient PC team  Limited out-pt PC clinic with the KCC  Cancer LifeNet Program in place  Updating Advance Directive policy and in-servicing all team members  Physician Champion--Oncologist board certified in oncology & PC and Medical Director on-board  NP expertise  Leadership with background in PC/Hospice care University of Maryland Upper Chesapeake Health University of Maryland Upper Chesapeake Health 7

Workgroup  Established workgroup Summer 2014  Identified key TMs/leaders  Included physicians in the early planning phases  Literature review as to what has been done  Reviewed national metrics and determined outcome measures  Looked at various existing models  Developed our model 8 University of Maryland Upper Chesapeake Health

Palliative Care Models  Embedded Specialist RN/MD  Inpatient Consult Service • Dedicated Inpatient Unit  Outpatient Clinic • Home-Based Care  Existing at UM UCMC 9 University of Maryland Upper Chesapeake Health

Hallmarks of an Integrated Program Advisory Board, 2013  Oncologists trust the palliative care team  Palliative care team scrupulous about care coordination  Advance Care Planning routine for all cancer patients  Palliative care team highly visible in cancer center  Clinicians share responsibility for initiating palliative care  Oncology clinicians trained to provide palliative care 10 University of Maryland Upper Chesapeake Health

Integrated Palliative Care Model, Kaufman Cancer Center • Patient -Centered Care • Patient & Family • Advance Care Planning • KCC Providers & Team Members • AD & MOLST • Body, Mind, & Spirit--Integrative • Community-Based Health Care Health--Meditation, Yoga, massage, Providers MBSR, exercise • Goal of Care Meetings • Support Groups • PC Case Conference • Individual & Family Counseling • EMR Documentation Support • Community Resources--Hospice, Communication Hooper House, Palliative HC • ST Bereavement Coordination Symptom of Care Management • KCC Treatment Teams -- Infusion, • Assessing symptoms--physical, Radiation , Surgery, & Support Care emotional, psychological, financial • Multi-D Providers toxicity • In-patient Care Teams--Palliative • Recommendations from PC Case • Out-Patient Palliative Care Clinic Conference- • Community-based Providers--home • Medication Management care, hospice, other MDs • Specialist Referral • Choosing Wisely • Behavioral Health & Supportive Care • PC Case Conference University of Maryland Upper Chesapeake Health 11

Palliative Care Decision Process • Evidence of non-curative disease and/or • Performance Status Assessment 2 or > Physical • Nurse Navigator reminder • Palliative Care 5-Item Questionnaire in ARIA • Names forwarded to Multi-D secretary for conference Trigger • Palliative Care Conference • Communicate with oncologist the PCC recommendations PC • Goals of Care Meeting with MD & MSW, other disciplines prn Confirmed • Practice schedules appointment • Notifies Multi-D secretary to reserve consult room Schedule Appt University of Maryland Upper Chesapeake Health 12

Palliative Care 5-Item Questionnaire Glare, P.A., et al. (2011). Palliative Care in the Outpatient Oncology Setting: Evaluation of a Practical Set of Referral Criteria. Journal of Oncology Practice, 7(6) , 366-370. University of Maryland Upper Chesapeake Health 13

Palliative Care Conference Model PC CC Team Members PC Conference • Nurse Practitioners Weekly at 8am Palliative Care • Conference Summary Sheet • Nurse Navigators completed • Infusion Center Nurses Interdisciplinary team reviews • • Radiation Nurses newly identified patients • Social Workers Recommendations • communicated to oncologist for • Nutritionist further direction and/or • Pharmacists schedule Goals of Care meeting • Hospice House rep Started meeting October 2014 • • In-pt PC nurse practitioner • Physicians ad hoc University of Maryland Upper Chesapeake Health University of Maryland Upper Chesapeake Health 14

Palliative Care Conference Overview  Patient Presented--review of current status  Understanding of the disease status ,treatment response & overall prognosis of patient  Current functional status of patient  Patient/family dynamics  Discipline Report  MD/NP  Nurse Navigator & Treatment Nurse  SW  RD  Summary & Recommendations:  Symptom management  Goals of Care/Advance Care Planning Patient & Family meetings  Document in EMR University of Maryland Upper Chesapeake Health 15

PC Specialists Workgroup  Moving towards —  Self-selected group with Subject Experts i.e: interest in PC Pharmacist – pain  Agree to attend meetings mgmt./conversions and commit to additional ONN – Goals of Care educational development meetings  Education module  Palliative Care developed Certifications  Invite subject experts to present University of Maryland Upper Chesapeake Health University of Maryland Upper Chesapeake Health 16

Goals of Care Meeting  Pt/Family understand current medical status  Summarize “big picture”  Respond to emotions  Decision-making  Goal Setting  Document and update team 17 17 University of Maryland Upper Chesapeake Health

Goals of Care & AD Resources & References S etting up the interview  SPIKES protocol (CMAJ, 2013)  The Mount Sinai Hospital P assessing patient’s Palliative Care Goal-Setting- Conference Pocket Card Perception http://emupdates.com/wp- I obtaining the patient’s content/uploads/2009/11/goal-setting- conference-pocket-card-mssm.pdf Invitation Palliative Care and the Human  Connection: Ten Steps for What K giving Knowledge and To Say and Do (Video from, information to the patient CAPC)  The One Slide Project E addressing the  Respecting Choice patient’s Emotional with  The Conversation Project Empathic responses  Advance Care Planning Canada S Strategy & Summary University of Maryland Upper Chesapeake Health University of Maryland Upper Chesapeake Health 18

A Shift in Culture in the KCC  Proactive vs reactive  Expanded awareness & language sensitivity  Palliative care & hospice  Advance Directives/MOLST & Advance Care Planning  Population Health & Value- based care 19 19 University of Maryland Upper Chesapeake Health

Community Partnerships  Hospice and Palliative Care Agencies  Meet and Greet-Dec 2014  Hospice House Rep March 2015 20 20 University of Maryland Upper Chesapeake Health

Palliative Care Dashboard Advisory Board, 2013 University of Maryland Upper Chesapeake Health 21