Palliative Care Consultation

1. Palliative Care Consultation May 19, 2010 Department of Veterans Affairs Audio Conference 1:30 – 2:30 PM EST Rodney O. Tucker, MD MMM Medical Director Inpatient Palliative Care Programs University of Alabama at Birmingham Palliative Care Leadership CentersTM Birmingham, AL E-mail: rtucker@uab.edu Karl Lorenz, MD, MSHS VA Greater Los Angeles Healthcare System Director, VA Palliative Care Quality Improvement Resource Center (QuIRC) Los Angeles, CA E-mail: karl.lorenz@va.gov

2. Learning Objectives • In this audio conference, you will: • Discuss the role and unique features of a comprehensive palliative care consultation • Understand the utility of a specialized template that captures the components of a palliative care consultation • Discuss the practice pearls of appropriate consultation etiquette

3. Opening Thoughts on Palliative Care Consultation • Palliative care consultation is one of the single • most important tools in development of a • comprehensive palliative care service line • In its broadest sense the palliative care • consultation is an exercise in effective • communication • Done well the palliative care consultation is • also a valuable “marketing” and educational • tool

4. First Steps • Know the referring source (stakeholder) • Understand the question • Involves initial questions to referral source • Should involve the bedside team/RN’s as well • Correlate culture with the initial response to the • consultation

5. Principles of Consultation Etiquette • Determine the question • Triage urgency • Gather your own data • Brevity • Specificity • Plan ahead

6. Principles of Consultation Etiquette (cont’d) 7) Honor turf 8) Teach with tact 9) Personal contact 10) Provide follow-up Adapted from: Goldman and Lee. Archives of Internal Medicine. 1983 and CAPC e-learning course on Consultation Etiquette.

7. Unique Characteristics • Tend to promote evaluation and treatment planning in all four domains of suffering • Emphasize patient AND family as the units of care • May address prognostication, QoL, and patient centered goal setting • Interdisciplinary involvement is promoted as standard of care • Address difficult goals of care which may not have been previously addressed

8. Honest Questions Re., Consultation What are we trying to achieve for patients and families in palliative consultation? What elements are critical to an effective palliative consultation (e.g., pain vs. pruritus)? How can we learn more about critical, common palliative practices (e.g., opioids in renal failure)?

9. What Do We Want to Achieve?

10. What Are Critical Elements? “The Garden Poppy Heads with Seeds made into a Syrup, is…to good effect used to procure rest and sleep in the sick and weak…” (N. Culpepper 1652)

11. Can We Learn From Experience? *96 million observations (40 million >0) VA pain ratings 2003-2006

12. VA Initiatives • Define palliative care consultation as a quality of • life focused task • Create informatics tools (VA National Clinical • Template) to allow us to: • Capture our work including critical elements seamlessly • Ensure and learn from our common practices

13. Defining Palliative Consultation QuIRC, Hpalliative care Offfice, Quality and Performance, with VISN Program Managers VA Health Information Management Service (HIMs) – apply CPT standard to reflect palliative care practice Goal to encourage a common clinically meaningful standard

14. Defining Palliative Consultation(cont’d) • Encourage quality of life assessment • Pain and other symptoms • Social context • Spiritual wellbeing • Communication and care planning • ‘Level 3’ = ‘detailed’ history, physical, and low complexity decision making • Also qualify on time (40-55 minutes) if half or • more spent in counseling • Credentialed provider – MD, NP, PA, CNS

15. VA National Clinical Template (cont’d) • Primary aim - serve ‘essential clinical practice’ • Programmatic assessment and planning • Quality assessment and improvement • Future research capabilities • Combines workload and clinical documentation • Generally comprehensive palliative consultation • – no required clinical elements • Enriched priority areas

16. VA National Clinical Template (cont’d)

17. VA National Clinical Template (cont’d) • ‘Reminder dialogues’ capture key information to databases as ‘health factors’ • Modular to enhance flexibility • Development steps • Identify priority concepts and items • Characterize VA informatics experiences • Interview experts about key items and QI needs • Review measures systematically • Operationalize concepts • Develop Word, CPRS prototype • Solicit field input and modify • Revise Version 1.0 for release

18. VA National Clinical Template (cont’d) • August 2010 Version 1.0 (GLA, National Clinical Reminders, and HPC Sharepoint) • ‘Installation and implementation package’ • Workload documentation essential but use of National Clinical Template optional in FY11 • Contact QuIRC - Kristen Cribbs (kristen.cribbs@va.gov) (310) 478-3711 (x 48380) • Work with VISN Program Managers and your facility Clinical Applications Coordinators to install / modify template in August

19. Practice Pearls • “How can we help?” • Training initial referral intake staff re: customer service • Accessibility and Ease of consultation • One line or method of notification • Consistent staffing to every degree possible builds • rapport

20. Practice Pearls (cont’d) • Clarify and Triage as not to over-promise and • under-deliver • Consider engaging other team members • (coordinator, educator, pastoral care, SW, • mental health provider, hospice rep, etc.) in • initial family conference • Value a personal phone call • Discuss recommendations with managing or • bedside team

21. Practice Pearls (cont’d) • Consultation documentation is not the place to • criticize previous management, etc. • Document as a teaching tool may or may not • be appropriate depending on culture

22. References • Goldman and Lee. Ten Commandments for Effective Consultations. Arch Intern Med. 1983: 143: 1753-1755. • Weissman DE. Consultation in Palliative Medicine. Arch Intern Med 1997: 157: 733-737. • Henkel G. Palliative Consult. The Hospitalist Med. 2006 Jan 23; 166(2): 227-230.

23. Additional Resources A Guide to Building a Hospital-based Palliative Care Program http://www.capc.org/support-from-capc/capc_publications/the-guide/ Consultation Etiquette – a palliative care eLearning course http://campus.capc.org/PalliativeCareCourses/ConsultationEtiquette

24. Question & Answer Period Thank you for joining us today! ABOUT CAPC The Center to Advance Palliative Care (CAPC) provides health care professionals with the tools, training and technical assistance necessary to start and sustain successful palliative care programs in hospitals and other health care settings. Located at Mount Sinai School of Medicine, CAPC is a national organization dedicated to increasing the availability of quality palliative care services for people facing serious, complex illness.

25. Audio Conference Evaluation At the conclusion of this audio conference, complete the following short evaluation to provide us with your feedback. Go to: http://www.surveymonkey.com/s/VA_survey NOTE: This survey will only be available for 7 days following the presentation of this audio conference.

26. Continue the Discussion! At the conclusion of this audio conference, we welcome you to continue the discussion with VA faculty and your peers. Post your questions and comments on the VHA National HPC Mail Group! • Go to the Global Address Book in Outlook • Scroll down to VHA National Hospice & Palliative Care” • Post your message and comments