Support: Lessons Learned from a Without Walls Palliative Care - - PowerPoint PPT Presentation

An Extra Layer of Outpatient Support: Lessons Learned from a “Without Walls” Palliative Care Program

Leanne Yanni, MD Medical Director, Palliative Medicine Bon Secours Virginia Health System

January 22, 2015

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An Extra Layer of Outpatient Support: Lessons Learned from a “Without Walls” Palliative Care Program

Leanne Yanni, MD Medical Director, Palliative Medicine Bon Secours Virginia Health System

January 22, 2015

Objectives

➔ Examine the structure of a “without walls”

• utpatient palliative care program

➔ List quality end of life measures that may be

achieved as a result of outpatient palliative care

➔ Identify specific challenges faced in the first 2

years of program development

➔ Apply lessons learned while developing your own

• utpatient program

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Bon Secours Virginia Health System

➔ Catholic Health System ➔ Medical Group

– Operates Physician Practices, Home Health, and Hospice across Virginia – >600 providers; >165 locations – Accountable Care Organization

➔ Palliative Medicine is a specialty practice

within the Medical Group

➔ 3 of 4 Richmond Hospitals TJC Certified

(Advanced Certification for Palliative Care)

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Conduct Needs Assessment

Why?

Vision

➔A dynamic multi-faceted Palliative Medicine practice that provides care

without walls to meet the needs of patients with serious illness

Align Vision with Health System Priorities

➔Mission to care for the “poor and dying” ➔Accountable Care Organization ➔Enhance quality / reduce cost

“Provider Conscience”

➔If we had just seen this patient before they were admitted. ➔What is going to happen to this patient after discharge?

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1

Outpatient: The 1st Year

➔ Key = Medical Group ➔ Set up as an Office Practice ➔ Shared space for 1st year ➔ Patients by MD referral ➔ MD – RN Model

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Facilities Other Offices Home Hospice

Office Practice

Hospitals

Select the Venue 2

Outpatient Parameters

➔ Referral process ➔ Electronic Health Record

Templates

➔ ESAS ➔ Advance Care Planning ➔ Discharge Folders

– Brochure – Opioid Safety – After Visit Summary

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Scheduling Standardization

➔ All appointments are 60

minutes

➔ 6-8 patients/day ➔ NN in room with MD for

all New and most Follow Up visits

➔ Weekly interdisciplinary

team rounds (2+ hours)

➔ Visits outside of office day

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Outpatient Referral Form

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Outpatient Referral Form

ESAS and Advance Care Planning

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Outpatient Parameters

• Full day at 2 sites
• Following ~ 80 patients
• ~ 20 referrals/month
• 3 New Appointments/Office

Day

• Visits “without walls” at
• ther locations:

– Oncology Office – Infusion Center – Skilled Nursing Facility/Nursing Home – Home +/- Hospice

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FY12 FY13 FY14 FY15 Days 1 2 2-3 3-4 MD 0.2 0.4 0.6 1.0 NP 1 RN 1 2 3 3 LPN 0.4 1 1 2

Staffing Estimates

Visits “Without Walls”: How?

➔ “Without Walls” based on:

– Urgency of clinical need – Patient functional status (Can they get to other appointments?) – Patient convenience (Oncology/Infusion Center)

• Concurrent Scheduling

➔ Most Difficult

– Chronic non-urgent visits

➔ MD/NP “Flex” Scheduling

– 8-12 non-inpatient weeks/year per provider – Non-inpatient weeks cover “without walls” need

➔ Administrative Time

– 0.5 of Medical Director

➔ Full-Time Nurse

Practitioner and Nurse Navigators

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Staff Schedule

The Nurse Navigator

➔ Ambulatory Clinical

Resource for Advanced Medical Home

➔ >65 Nurse Navigators

(Embedded and Virtual)

➔ Intense training process

including specific electronic health record documentation

➔ 3 full time Palliative Nurse

Navigators – Medical Home budget

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The Palliative Nurse Navigator

➔ Specifically selected and interviewed ➔ Specific competencies developed ➔ Communication skills emphasized ➔ Integrated into office visit model ➔ Trained in Advance Care Planning ➔ Assess and address needs in “without

walls” visits

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Our Space

The Challenges

Identity Crisis

Sent: Monday, October 06, 2014 10:24 AM To: BSR-Palliative Outpatient Subject: phone call Caller: Mrs. H Patient: Mr. H DOB: XX-XX-XXXX Reason for call: wants to know if we will come to house to give him flu shot and pneumonia shot or does she need to take him to drugstore. Call directed to: Hope Call back number: XXX-XX-XXXX Best call back time: when you can pls Level of urgency: Patient told to bring to drug store and response: “Done….she sounded a little

• disappointed. She said “ I thought this was

the sort of thing palliative would take care of”

➔ Palliative Medicine flyer in

new patient folder to describe services

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Things We Tried that Didn’t Work

➔ MD Referral Model ➔ Shared/Rotated outpatient

responsibilities with all MDs/NPs

➔ MD seeing patients

wherever they are / at any time

➔ Following patients in

Hospice that we don’t know well

Agreeing to see patients for the wrong reasons… Electronic Health Record Referral Statements

➔ “Referral received. Patient will

receive phone call from Palliative Medicine within 24 hours to schedule first available appointment."

➔ "Referral received. Patient not

• scheduled. Practice notified of
• ther resources to support patient

needs."

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Case Example

➔ 58 year old with end stage COPD, multiple admissions

• ver the past year

➔ Consulted inpatient while in ICU, began to work with

patient and family on understanding illness and prognosis

➔ Over several weeks post-discharge, symptoms and

needs escalated (calls, office & home visits with different staff members)

➔ Escalated to emergency, MD visit to home and patient

died that night without Hospice

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Recognizing the Need

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Lesson Learned

What is “failure”?

➔Any ED visit, Admission, or Death

BEFORE 1st Touch after referral Prioritize urgent needs

➔All referrals reviewed by LPN ➔Urgent referrals receive immediate

call by RN

➔Recognizing escalating need (see

graph) Lesson

➔Too much chronicity depletes the

ability to respond to urgent need

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Patient Need Time Graph of Patient Need

Outpatient Data Set

Measure Result Mean age 62.5 years Female 172/284 (61%) Mean Initial Palliative Performance Scale 63 Cancer* 179/273 (66%) Advance Directives* 193/269 (72%) Do Not Resuscitate 146/264 (55%) Deaths 145/259 (56%) Hospice Referral* all: 112/284 (39%) died: 104/145 (72%) Hospice Length of Stay median 21.5 days

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Data Set:

➔ Start to June 30, 2014 ➔ 284 unique patients

Measuring:

➔ Demographics ➔ Descriptors ➔ Quality measures ➔ ESAS ➔ Outcomes ➔ ACP ➔ Hospice LOS

Outpatient Visits by Year

Unique Patients # Encounters FY12 – 2nd 59 166 FY13 – 1st 76 206 FY13 – 2nd 72 200 FY14 – 1st 77 192 FY14 – 2nd 110 295

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1059 OP Visits February 2012 to June 30, 2014

Note: Data derived from billing, all outpatient, non-hospice codes

Length of Follow up

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Days between initial and most recent visit N

➔ Most patients we follow for

<30 days (160)

➔ Fewer patients we follow

longer (~90)

➔ 30 days to 6 months (60) ➔ 6 months to 1 year (~30) ➔ Even fewer we follow for >12

months (~20)

Low and High Frequency Patients

➔ 1 or 2 visits ➔ More patients (169) ➔ Higher % deaths (61%) ➔ Slightly older (64yrs) ➔ Higher % cancer (69%)

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High Frequency Patients Low Frequency Patients

➔ 5 or more visits ➔ Fewer patients (64) ➔ Lower % deaths (43%) ➔ Slightly younger (60yrs) ➔ Lower % cancer (53%)

# Visits/Patient and Hospice LOS

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21 23 29 33 33 39 44 41 41 5 10 15 20 25 30 35 40 45 50 1 2 3 4 5 6 7 8 9 10

Hospice Median LOS (days)

Minimum number of clinic visits (at least N visits)

Basic Financials

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1/1/12- 8/31/12 9/1/12- 8/31/13 9/1/13- 6/30/14 Billed 69,217 154,725 156,765 Reimbursed 23,888 (33%) 53,699 (35%) 46,668 (30%) Number of Visits 173 406 398

Outcomes

➔ Most patients have or complete an Advance

Directive with us

➔ Most patients are dying with support of Hospice

– High percentage are referred to our health system’s Hospice program

➔ Among all patients who die, their median LOS in

Hospice is longer than the national average

➔ The more visits we with have with a patient, the

longer their Hospice LOS

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Next Steps

➔ Full-Time LCSW for outpatient services ➔ Integrated “Palliative Home Model”

– Similar to “AIM” or “Bridge” programs – Previously in Home Health

• Home Health limitations to provide service to patients not homebound
• r without skilled need

– Hospice model (RN / LCSW) with provider support (MD / NP) – Developing triggers for referral based on “compassionate care” population

➔ Honoring Choices Virginia ACP Pilot

– Richmond Community / Respecting Choices Model

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Summary and Conclusions

➔ With resource support, Palliative

Medicine can provide care “without walls”

➔ The empowered Nurse Navigator is

an essential ambulatory resource for the seriously ill

➔ We have learned many lessons,

with the most critical being “the graph of patient need”

➔ Bon Secours Virginia will share

resources and lessons learned throughout their palliative care journey

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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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Leanne Yanni, MD Medical Director, Palliative Medicine Bon Secours Virginia Health System Leanne_Yanni@bshsi.org