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Palliative Care In Action – Bridging Gaps in Care

Palliative Care In Action – Bridging Gaps in Care. Martha L. Twaddle MD, FACP Medical Director, PCCHNS Assistant Professor of Medicine Director of Palliative Care Rush Medical College Evanston - Northwestern University School of Medicine

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Palliative Care In Action – Bridging Gaps in Care

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  1. Palliative Care In Action – Bridging Gaps in Care Martha L. Twaddle MD, FACP Medical Director, PCCHNS Assistant Professor of Medicine Director of Palliative Care Rush Medical College Evanston - Northwestern University School of Medicine President, The American Academy of Hospice and Palliative Medicine

  2. Center to Advance Palliative Care Mount Sinai School of Medicine 1255 5th Avenue, C-2 New York, NY 10029 212-201-2670 office 212-426-1369 fax 212-201-2680 event line www.capcmssm.org A national initiative supported by The Robert Wood Johnson Foundation at the Mount Sinai School of Medicine.

  3. Case Study - Rose • Consult called by Internist – big picture needs • “I hope we can keep her alive” • Refractory pneumonia, myelodysplasia • Provided significant psychosocial support • Patient articulate of illness and sense of prognosis, 92 yo husband NOT!

  4. Palliative Care “Modern” Medicine Hospice

  5. Case Study - Rose Palliative Care Service • Consultation Team • Followed Rose for several days while receiving continued disease modifying treatments • Much time spent with family clarifying and supporting goals of care.

  6. Palliative Care Consult • Reimbursements MDs of same specialty can see a patient on the same day if they link their charges to different diagnoses Primary MD  Primary Diagnosis Consultant in Palliative Care  Symptoms

  7. Palliative Care Consult Team • How do we learn? • Post-graduate MDs traditionally learn practical knowledge through consultation • How do we facilitate communication? • Consultation provides give and take • Forges relationships and networking • How do we build support? • For patients & families • For the professional caregivers • MD’s, RN’s and other staff

  8. Palliative Care Consult Team • Additional goals • Education – disseminating information • Diffusing tensions and intensity • The blessing of the “second opinion” • Spreading the support for patients and families • Supporting the professional caregivers • Affirming the Art of Caring

  9. Giving Shape to the Opportunities Palliative Care Service • Consultation Team • Inpatient Unit • Hospice Unit • Palliative Care Unit • combo • Scatter Beds

  10. “Admission” to Inpatient Hospice • Admission • Physician  Palliative consultation • Like the Rehab model • From hospital, home or nursing home • Discharge/readmit - nonDRG • Relatively short ALOS

  11. Scatter Beds • Much more challenging given the variable of nursing support • Multiple contractual relationships • Direct admissions within hospital • Discharge/readmit for Hospice GIP • Team-oriented care • Enhancement of care in familiar setting

  12. Case Study - Rose • Transferred to the Hospice IPU • The IntensiveCaringUnit • Aggressive Palliative Care (beyond scope of other setting) • Intensive End-of-Life Care • Stabilization • Transitionto another site of care

  13. Relationships with Physicians • Consult Model is key • Think the Rehab model • Collaboration and support • Enhancing their care of their patient • Enlarging the circle of support – not replacing but expanding the concept of team!

  14. Role of Medical Director • Hospice Med Directors should be Consultants in Palliative Medicine • Educators in the field • Intensivists in End-of-Life Care • Liaison with Interdisciplinary team

  15. Integrating the Interdisciplinary Team • Consult Model • Formal Team discussion of cases before or after consult • Quarterly meetings with Hospital Administration Team • Minutes • Action plans • Quality Assurance

  16. Impact on the Culture of the Hospital • Hospice and Palliative Care are not “soft alternatives” or a consolation prize! • Enhanced understanding of Hospice & Palliative Care • Affirmation of professional caring • Diffusing stress • Support for families and professionals • Enhanced Wellness

  17. Impact on Patient Care • Best Practices • Outcomes • Pain and Symptom Control • Average Initial VAS at consultation = 7 • 24 hour follow-up = 2 • Cost – appropriate utilization

  18. Continuum of Services • Any Stage • HomeCare • Community Outreach • Mobile Medical Unit • Personal Care Assistance • Palliative Care Consult Program

  19. Case Study - Barbara • Followed for over 2 years in Ambulatory setting • Very clear of goals of care • Unexpected decline during and after XRT • Admitted to Home Care • Transitioned to Medical Home Visits

  20. Case Study - Barbara • Improved – seen as MD home visit • Declined again – admitted to Hospice InPatient Unit • Home briefly with Hospice Home Services • Re-admitted to IPU and died approximately 10 days later

  21. Advantages to Continuum • Brings Services to the Community Level • Provides services in the “right” setting • Meets Patient Needs • Increases Patient Choice • Increases Patient/Family Satisfaction

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