URMC Palliative Care Program Highlights

1. URMC Palliative Care ProgramHighlights Timothy Quill, MD Program Director Sue Ladwig, MPH Quality and Research Coordinator

2. Our Mission We strive to provide the highest quality patient-and-family centered care for seriously ill patients through excellent clinical consultation, comprehensive educational programs, innovative research and ongoing performance improvement. Our program is modeled on and follows the Clinical Practice Guidelines for Quality Palliative Care, Second Edition, by the National Consensus Project

3. How Palliative Care Fits in at URMC

4. PC Program Organizational Chart • Maria Milella • Program Administrator • Timothy Quill, MD • Palliative Care Program Director • Consult Service • Research & • Quality Improvement • Medical Education • Other Activities • Development & Fundraising • 11 Physician Consultants/ Attendings • 3 PhD trained • Co-Directors with • 1 FTE Coordinator • Educating Medical and Nursing students, Medical Residents, & Faculty • 3 Nurse Practitioners • Community Service (includes Pain, Adv. Directives, MOLST, PEGS, VNS, MCMS, Hospice • 4-12 Sussman Unit • Recent Grants • Hospital Wide Noon Conference Series • Music, Massage, Bereavement and Volunteers • State and National Activities • Fellowship Program

5. Indications for Palliative Care

6. Consulting vs. Attending • Consults are appropriate for seriously ill patients with: • Uncontrolled or hard-to-manage symptoms • Patients with psychosocial, emotional or spiritual distress • Uncertainty about treatment options or goals of care • Need for coordination of care • Also consider Palliative Care Consult if: • Multiple hospital admissions in the last 3 months • Not surprised if the patient died in the next 6 months • Prior palliative care consult • Palliative Care may become Primary Attending for patients who: • Are already on or transitioning to Hospice, and/or •  Want a purely palliative approach (no active disease directed treatment) • Patient and family are in agreement with the plan

7. How many patients do we see? Hospitalized Adult Patients per Calendar Year

8. Outpatient Visits Total N PC Adult Outpatient Visits, 2006-2010 Five palliative care trained physicians and one nurse-practitioner currently offer adult outpatient consults and follow-up care.

9. What illnesses do our patients have?

10. Why are patients referred to us?

11. Capacity to make medical decisions Percentage with full, partial and incapacity at initial palliative care consult

12. Our patients are very ill Performance Status* of Inpatients at Initial Consult Scale 70 - 100 Scale 10 - 30 Scale 40 - 60 * Performance Status Scale assesses functional ability, and ranges from 0 (dead) to 100 ( normal)

13. Where do our hospitalized patients go? Discharge Dispositions

14. Impact of Palliative Care • Improved Symptom Management Scale 3 = Severe 2 = Moderate 1 = Mild 0 = None

15. Our 4 New PI Measures • Frequency of Pain Assessment Among Inpatient Hospice Patients Goal: 90% will have 12 documented assessmentsin 24 hours • CPR Preferences at Initial Palliative Care Consult Goal: 90% with CPR wishes documented (excludes symptom management only) • Screening for Depression Among Palliative Care Patients with Capacity Goal: 90% with depression screen in initial consult note • Identification of Surrogate Decision Makers for Patients Lacking Full Capacity Goal: 90% with surrogate decision maker identified or sought in a principled way

16. Methods • 4 months of Baseline Scores from retrospective chart reviews for May – August 2011 • Sampling rate of 20% of cases (minimum of 10 and maximum of 20 cases per month) • Sampling rate and denominator used: • Pain Scores = Percent with > 12 documented pain scores (sleeping counts if documented) on first full 24 hour-day on inpatient hospice [10 cases per month] • CPR Preferences = Percent with CPR preference documented or considered in initial palliative care consult note (exclude sx. mgmt only) [15 cases per month] • Screening for Depression = Percent of patients with decision making capacity screened for depression in initial palliative care consult note [10 cases per month] • Surrogate Decision Makers = Percent without full decision-making capacity who have a surrogate decision-maker identified initial palliative care consult note [10 cases per month]

17. The Visit Itself • Opening presentation • Members of the organization • Palliative Care Team • Individual tracers • On our service (inpatient hospice) • Consulting only patients • Performance improvement • Four measures • First four months of data • Competency and credentialing • Feedback