Palliative Care: Making it Happen

1. Palliative Care:Making it Happen CAPC Management Training Seminar October 23-25 San Diego, California Diane E. Meier, MD, FACP Professor, Departments of Geriatrics and Medicine Mount Sinai School of Medicine Director, Center to Advance Palliative Care in Hospitals and Health Systems a Robert Wood Johnson Foundation - Mount Sinai School of Medicine initiative 102503

2. Putting it all together: Themes • Define palliative care without requiring reference to terminal care: • Palliative care is needs-based not prognosis based- it is a simultaneous care model-delivered at the same time as all other appropriate treatments for patient and family • Align messages- with the mission and concerns of key decision-makers and other audiences • Measure- both for quality and to justify your existence • Finance with a diversified portfolio- There is funding for this type of care. • Many ways to get there- Model must fit your setting’s needs and your leadership strengths.

3. CAPC Resources • National meetings • Palliative Care Leadership Centers • Publications: The Case; The Guide • Website • CAPC Manual • Strategic partnerships

4. CAPC Meetings Management and Training Seminars: Our core curriculum on how to start and sustain a palliative care program including- • program rationale and needs assessment; • financing and business planning; • leadership; • tools/templates; • program/staffing models including hospital-hospice partnerships; • marketing and communications; • alignment of message and mission with key audiences; • outcome measurement and quality improvement Next meeting May 2004, Minneapolis.

5. CAPC Publications • NEW! Guide to Establishing a Palliative Care Program • The Case for Hospital-Based Palliative CareAvailable outside, order what you need from CAPC • CAPC Brochure- who are we, what do we offer? • CAPC Marketing Tools and MD Survey • Planning a Hospital-Based Palliative Care Program: A Primer for Institutional Leaders Nov. 2000. • Hospital-Hospice Partnerships in Palliative Care Jan. 2002, with NHPCO • Palliative Care: An Opportunity for Medicare March 2002, with the Institute for Medicare Practice

6. www.capc.org • ALL NEW!! • Register for the Palliative Care Leadership Center site visits • Full text of all national meeting presentations and appendices, downloadable PowerPoint • All CAPC publications in PDF format • Spread sheet financial templates, cost avoidance analyses • Needs assessment tools and forms • Standardized progress notes, billing cards, orders, care pathways • Position descriptions, staffing models • Program models • Marketing tools, brochures • Billing strategies • Alternate funding sources via philanthropy, foundations • Case studies • Audio files of Grand Rounds conference calls • Call or email us if you can’t find something.

7. www.capcmanual.info Charles von Gunten and Frank Ferris San Diego Hospice Russ Portenoy and Myra Glajchen Beth Israel Medical Center, NYC • Web-based practical guidance on how to start and sustain a palliative care program

8. CAPC Projects-1 • National Consensus Project on Quality Palliative Care: Essential Elements and Best Practices Establishing standards for palliative care with NHPCO, HPNA, AAHPM, and Partnership for Caring • JCAHO: Identification of existing accreditation requirements which could be met through establishment of a palliative care program; positioning palliative care as a platform for meeting the new pain standards; working towards new JCAHO palliative care certification requirements

9. CAPC Projects-2 • Hospice-Hospital Collaborations with NHPCO: Advancing palliative care through integration and application of hospice workforce and skill set to non-hospice patients across the continuum • Finance Study: Palliative care business models and their outcomes in a range of clinical settings

10. CAPC Strategic Partnerships • EPEC, ELNEC, PEELC, EPERC, LastActs, PfC, PDIA • National Hospice and Palliative Care Organization- NHPCO • Joint Commission for the Accreditation of Healthcare Organizations- JCAHO • Centers for Medicare and Medicaid Services- CMS • National Health Policy Forum- NHPF • University Hospitals Consortium- UHC • The Advisory Board • Association of Academic Health Centers- AAHC • American Association of Medical Colleges- AAMC • Voluntary Hospital Association- VHA • National Quality Forum- NQF • American Hospital Association- AHA • Blue Cross Blue Shield of America- BCBSA • Veterans Health Administration- VA • The Leapfrog Group

11. Palliative Care Leadership Centers • Hands on training and tools to fast -track your palliative care program • Funds 6 exemplary palliative care programs to serve as visiting and training sites for new program leaders • Site visits to start in February 2004 • Information and registration on www.capc.org

12. Palliative Care Leadership Centers • Fairview Health Services: Minneapolis MN • Massey Cancer Center of Virginia Commonwealth University Health System: Richmond VA • Medical College of Wisconsin: Milwaukee WI • Mount Carmel Health System: Columbus OH • Palliative Care Center of the Bluegrass: Lexington KY • University of California, San Francisco: San Francisco, CARegister at www.capc.org!

13. Education is Not Optional Training opportunities • ELNEC www.aacn.nche.edu/elnec • EPEC www.epec.net • DELeTCC www.deletcc.coh.org • EPERC www.eperc.mcw.edu • AAHPM www.aahpm.org • Harvard www.hms.harvard.edu/cdi/pallcare/ • Fellowship training www.aahpm.org • ANP palliative care training programs, ANCC certification www.hpna.org www.nursingworld.org • MD Certification: ABHPM www.abhpm.org

14. Is all of this having any impact? • EPEC ELNEC DELETCC EPERC PEELC LastActs CAPC PDIA PfC NHPCO HPNA AAHPM ABHPM HPNA NIH ACGME LCME JCAHO • 1999: 337 hospital based palliative care programs in the U.S. (AHA annual survey and Pan et al + Billings et al JPM 2001;4:315.) • 2002: >800 hospital based palliative care programs in the U.S.(AHA annual survey), 20% increase over 2001 • In 2003- 1200 MDs now ABHPM-certified in palliative medicine.

15. Getting to the tipping point: what do we need to do? • Start somewhere: Examples presented here not intended to cover every setting. Borrow what fits, leave what doesn’t. An imperfect program is much better than no program. Build and grow from there. • Align palliative care’s quality message with the business needs of healthcare • Cultivate public awareness and demand • Focus on those with chronic, complex serious illness - that’s the real need • Get training and knowledge for yourself and your colleagues

16. Tipping Point: Policy Needs • Education: Make sure every medical and nursing school teaches palliative care: increase fellowship training, NIH funding, ABMS specialty status to obtain GME dollars; actualize ACGME and LCME requirements • Tweak the payment system: DRG modifiers, CPT coding changes for E/M, hospice payment changes • Demonstration Projects: Policy change to test payment for complex care management and palliative care across settings (Frist-Kennedy, Oberstar bills) • Change the regs: Reduce or eliminate perverse regulatory and payment incentives for hospice/homecare/hospital/nursing home collaboration • JCAHO certification requirements for palliative care • Payment incentives: Preferred hospital status, quality incentives to hospitals with palliative care programs

17. Common barriers to getting started • “I don’t know enough about palliative care.” • “I don’t have time.” • “There’s no one here with the necessary training.” • “Our doctors will never refer.” • “We just keep having meetings but never seem to actually get started.”

18. “I don’t know enough about palliative care.” • Get training (EPEC, ELNEC, DELeTCC, AAHPM-HPNA, Harvard advanced courses) • Subscribe to the J of Palliative Medicine. Get the Oxford Textbook of Palliative Medicine • Do a site visiting program (Cleveland Clinic, Beth Israel Med Ctr in NYC, San Diego Hospice, others) • Take a year off and do a fellowship or an APN degree program

19. “I don’t have time.” • Think hard about what you really want to do with the rest of your professional life. • Rotating core team of docs and nurses- take turns • Recruit help from outside- call leaders of APN programs, contact fellowship training programs. • Retrain or cross-train existing interested staff- hospitalists, oncologists, geriatricians, retiring MD leaders.

20. www.epec.net -MD www.aacn.nche.edu/elnec -RN www.deletcc.coh.org www.EPERC.mcw.edu APN www.hpna.org Fellowships www.aahpm.org Site visiting programs Read Harvard course Go to the AAHPM annual meeting Use the web www.palliativedrugs.com www.growthhouse.org www.stoppain.org Learn by doing! “Our hospital doesn’t have expertise in palliative care.”

21. “Our doctors will never refer.” • Identify and empower opinion leaders, MD + RN champions • Start slow, lead through competence, availability, word gets out • Focus energy on the low hanging fruit, not the curmudgeons • Critical mass>rising demand • Audience-specific marketing, survey docs on their needs • Patience, persistence, eyes on the prize

22. “We just keep on having meetings but never seem to get started.” Visit a Palliative Care Leadership Center Hands on training and tools to fast-track your program: “The site visit program made all the difference. Because of what our hospital staff learned, our palliative care program now has more patients, a larger budget, and much more legitimacy through out the hospital. It really helped to have a leader in the field behind our efforts.” Erin Rhatigan, RN, HPNC Community Hospital Monterey Peninsula

23. Advice to local champions: Just do it! Remember, it’s better to beg forgiveness than to ask permission… When you begin you just start doing it. von Gunten J Pal Med 2000;3:115-122.

24. Our healthcare system is enormously wealthy… • In the passion, skill, and commitment of its professionals • In the privilege and rewards of the work • In the strength and capacities and gratitude of patients, families, and communities • Look around this room!

25. Evaluations • Tell us what else you need • Tell us what we could be doing differently • We really want your feedback so we can help you start and sustain your palliative care program

26. Thank you