The Palliative Medicine Consultation Service :

1. The Palliative Medicine Consultation Service: Strengthening the Hospital-Hospice Connection

2. Objectives • To describe usual processes in hospitals for chronically ill/terminally ill patients. • To define strategies for improving the alignment of hospital and hospice services through the hospital-based palliative consultation • To discuss the benefits to the medical staff, hospital, and hospice provided by the palliative care linkage • To identify fiduciary responsibilities of hospital and hospice to identify and help navigate hospice patients into and through the hospital from the community.

3. Current Hospital Realities • Care coordination among the various sub-specialists fragmented –no quarterback • Care communication among disparate family members fragmented • Dying patients may outpace hospice referral processes within hospitals • EDs rapidly cycle “palliative” patients to ICU or intermediate care • “Palliative Patients” transition from ICUs late or die there

4. The Current Trajectory • Chronically ill/terminally ill patient in crisis enters hospital via Emergency Department (ED) • Frequently from area SNF and readmitted to hospital • Often no family or surrogate accompanying them • ED Rapid Cycle model results in front loaded testing and seeking a bed--- NOT on processing goals of care

5. Paradigm: ED Patients Provided Life-Saving Effort • Business model = rapid throughput • Failure to Treat Regulations • ED physicians mediating between PCP at home and Hospitalist • Hospitalist doesn’t know patient’s history • Many EDs don’t “look back” • Few Hospice referrals initiated in EDs • YET, ED doctors and nurses describe gut level dissonance re: “palliative” patients

6. The ICU (Varies with open vs closed unit) • Average LOS “palliative pts” = 7-14 days • Average number of co-morbidities = 5 • Average number of sub-specialists = 5 • Each focusing on organ of specialty ( eg incremental change in Hgb ) • Yet ICU doctors and nurses describe gut level dissonance regarding “palliative patients”

7. The Hospital: Usual Processes • Chronically ill patients present with multiple co-morbidities • Multiple co-morbidities = multiple sub-specialists • Little face-to-face case discussion—mostly chart entry communication • Patients’/families’ expectations and education vary greatly • Options such as LTACH not presented in tandem with Hospice • “Trach em; peg em” often mantra

8. Patient/ Family Expectations and Education Varied Family members’ disagreement with physicians end in stalemate, result in elongated hospital stays Agreements reached can be undermined by one physician or one family member Family members’ communication with multiple specialists is confounding for them Hospital staff’s attempts to resolve may be lacking in objective clinical information or authority

9. Dying Patients Not Routinely Served by Hospice During Hospitalization Not understood by many hospitalists or PCPs Transition to Hospice Benefit/care not norm Hospice considered option at discharge Considered late in disease and hospitalization Lack of understanding of hospice as HMO

10. Discharge to Hospice • Patient/family experience it as abrupt • Hospice described by physician or case manager accurately or not • D/C Orders for Medications, treatments not congruent with Hospice POC • Advance Directives, RS not available • Patient/Family psychosocial issues from hospital not communicated routinely

11. How This Impacts Hospice • Front-end intensity to catch up • Patients unprepared or given unrealistic expectations • Little/no advance care planning discussions • Discharge Orders don’t include Hospice formulary so must locate and initiate appropriate pain medications; delays pain management • Psychosocial assessment information often not sent or not relevant

12. Sparse Physician Education in Palliative Medicine/Care • Palliative/Hospice rotation not required for Residents • Physician to Physician discussions inside hospital not readily available to community Hospice Medical Director • Internal Education/Marketing efforts limited to periodic inservices for the already “converted” physicians

13. Strategies Needed from within… What if there was an entity within the hospital --- to link hospital and hospice effectively ?

14. Strategies for Identification of Palliative Patients Patients with exacerbation of chronic illness who choose palliative life-extending treatment Patients receiving disease-directed treatment who may benefit from palliation of sx arising from disease or treatment Patients with serious, life-limiting illnesses for whom hospitalization often segue into Hospice Patients with acute event such as CVA

15. Strategies: Availability and Use of Palliative Care Tools • Standard admission orders and criteria • Rounds Worksheet • Indicators for Palliative/Hospice Referral • Procedures: e.g. Palliative Extubation • Hospice-friendly Psychosocial/spiritual assessments completed in hospitals • Educational materials • Staff/Students/physicians • Patient/family • Data Base

16. Strategies • Interdisciplinary Team Rounds, IDT Conferences • Palliative Consultation 24 hours/7 days - palliative physicians, nurse practitioners with coordinating, mentoring roles • Application of pain/symptom management protocols • Institutionalization of ELNEC, EPEC training into hospital orientation • Data collection, analysis, feedback

17. Strategy: Coordination and Presence Presence/collaboration – palliative professionals on hospital Ethics committees Queries to identify patients presenting in Emergency Department: Are they currently in a Hospice? Would they be best served in Palliative Framework? Do they need Hospice now? Rounding routinely in ICU, IMCU Interface with Radiation Oncology, Interventional Radiology routinely Understand reimbursement and compliance ramifications of all involved providers

18. Strategy: PMC’s Role in Medical Education • Teaching Fellows --- future physicians • Exposing all residents to principles of Palliative Care • Structuring practicum rotations • Providing didactic Conferences • Curbside mentoring of attending physician staff

19. Physician Education: Impact on Hospice • Physicians introduced to field of Palliative/Hospice medicine early • Physicians more knowledgeable overall will more effectively interface with Hospice • Hospice and palliative care become norms in medical education • More available practitioners in the field to staff Hospice Medical Directorships

20. Hospital Platform Which Supports Palliative Care Patient status (prognosis and functionality) assessed on admission Pain and Symptoms measured numerically and effectively managed Discharge Planning initiated early Psychosocial Assessment provided by SW Family System Involvement University Health Systems Palliative Care Benchmark Field Book 2004 Unpublished

21. How Palliative Consultation Achieves Benchmarks • Timing/frequency of rounding assessment • Timing of post assessment intervention • Timing of Palliative Intervention in ICU and Transfer • Timing of ED Palliative Triage and Intervention • Timing of Initial Advance Care Planning Assessment and follow-up discussions • Extent to which Family is involved • Valid, Reliable Measurement of Symptoms

22. How Palliative Consultation Helps Hospitals and Hospices Palliative Consult Hospital/Hospice Service Care Coordination ACP Appropriate Setting Discharge prep Physician, Staff Ed Pain/sx mgt. P/F Satisfaction. Access to ICU beds Less Diversion LOS MGT Physicians Awareness

23. Fiduciary Roles Hospice and Hospital in identification of patients Hospital: Query the patient routinely Look back process Notification of Involved Hospice Notification of non-coverage Hospice: Notification of Patient sent to ED Accompany patient Work with Hospital Case Mgt

24. Day in Life of Palliative Medicine Consultant • Arrive in the AM, gather team, and review status of patients on Palliative Care Unit (Palliative Care and Hospice patients) • Print Palliative Medicine Consultation List • See all new consults throughout hospital, including chart review, patient exam, family meeting and communication with attending physician • Determination of goals of care and care plan • Communicate same to all sub-specialists involved and write orders.

25. Day in Life of Palliative Medicine Consultant • Participate in Pre-rounding reviews of pain/symptom and medication mgt over previous 24 hours with pharmacy and others • IDT rounds on PCU at established time • Interface with ICU for complex patients, including de-escalation of treatments, benefits/burdens discussions, and goals of care • Interface with ED for patients with chronic illness needing hospitalization and help facilitate direct admission to the APCU

26. Day in Life of Palliative Medicine Consultant • Coordination with treating physicians, including radiation oncologist, medical oncologist, cardiologist, surgeons, etc. • Coordinate continuum plan with physician assuming care outside the hospital, hospice physician, ECF physician or primary care physician

27. Day in Life of Palliative Medicine Consultant • Review data with team, administration re: clinical, utilization, financial, and patient satisfaction outcomes.