Transitions in Care: Caring for our Patients Connecting our Partners

1. Provide the right care for each patient at the right time in the right care setting Transitions in Care: Caring for our Patients Connecting our Partners Jane Pike-Benton Executive Vice President Home Health & Care Transitions

2. Palliative Care Program - Mission Multi-disciplinary approach to shift the culture of our acute care facilities regarding serious illness and end of life care

3. Our Journey • May 2010 • MetroWest Medical Center Ethics Committee ask MetroWestHomeCare & Hospice to collaborate to develop an Inpatient Palliative Care Program • August 2010 • Saint Vincent Hospital and MetroWestHomeCare & Hospice team up to create a cross-continuum Inpatient Palliative Care Program • Fall 2009 • STAAR Team record review of readmitted HF patients reveals multiple patients with chronic HF and end of life concerns.

4. Our Journey • April 2011 • Inpatient Palliative Care Program begins consults at SVH Feb 2011 • Inpatient Palliative Care Program begins consults at MWMC

5. Palliative Care Program Structure Palliative Care Steering Committee • approves policies & procedures, physician order sets and drives the cultural shift through education Palliative Care Consult Team • meets with patients, family members and health care team members to discuss patient wishes and options

6. Palliative Care Program Structure Important to align the Palliative Care Program with the Ethics Committee, Cancer Care Center, Intensive Care, Emergency Department, Physicians, Hospitalists, Nursing and Chaplaincy, as well as other care team members

7. Additional Responsibilities • Policies and Procedures • Physician Order Set • Education at Physician, Nursing and Administrative Meetings • Schwartz Rounds • Palliative Care Informational Fairs

8. Resources Introduced in 1997 with funding from a grant from the Robert Wood Johnson Foundation Changes the way we talk about and plan for care at the end of life Simple to use Available in 15 languages Can also be completed on line

9. Hospital – Hospice Partnerships in Palliative Care Benefits as per NHPCO • Enhance pain and symptom management • Care concordant with patient-family preferences • Improved patient and family satisfaction • Reduced costs via shorter length of stay, decreased readmissions and less acute treatment ordering • Earlier transition of care to Bridge or Hospice care

10. Other Potential Benefits Morrison et al published an article in The Archives of Internal Medicine 2008;168(16):1783-1790. “Cost Savings Associated with US Hospital Palliative Care Consultation Programs” • Patients who are discharged savings- $1696 • Patients who die in the hospital savings - $4900 • Decreased readmission rate of patients with chronic and/or end of life illness

11. Palliative Care Outcomes 169 consults completed in the first 7 months Many patients with chronic illness unrelated to cancer 37% of patients were admitted from Skilled Nursing Facilities

12. It’s about how you live

13. Resources Five Wishes www.agingwithdignity.org NHPCO-National Hospice & Palliative Care Organization www.nhpco.org Center for Advancement of Palliative Care www.capc.org Resource for tools, articles, templates for policies and procedures

14. Discussion & Reflection