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Clinical & Institutional Needs Assessment / Varying Organizational Models

Clinical & Institutional Needs Assessment / Varying Organizational Models. Charles F. von Gunten, MD, PhD, FACP Director, Center for Palliative Studies San Diego Hospice & Palliative Care Associate Clinical Professor of Medicine University of California, San Diego. Objectives.

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Clinical & Institutional Needs Assessment / Varying Organizational Models

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  1. Clinical & Institutional Needs Assessment / Varying Organizational Models Charles F. von Gunten, MD, PhD, FACP Director, Center for Palliative Studies San Diego Hospice & Palliative Care Associate Clinical Professor of Medicine University of California, San Diego

  2. Objectives • Understand variables that influence program development • Describe leadership models • Differentiate among structures • Understand strengths and weaknesses • Select the structure that is best for you

  3. Outline • Needs Assessment • Models to meet needs • Leadership of Models • Strengths and Weaknesses • How to choose

  4. Outline • Needs Assessment • Models to meet needs • Leadership of Models • Strengths and Weaknesses • How to choose

  5. Needs assessment • Where are we now?

  6. Patient / Family Needs • Institutional Data • Demographics, diagnoses, patterns, costs, revenue • Chart Review • Pain / Symptom Scores • Documentation • Focus Groups • What is it like?

  7. Chart review • Reason for admission • Length of stay • Primary diagnoses • Treatments (ICU, IV’s etc) • Consultations

  8. Quality of care • Pain and Symptom Assessment and Rx • Psychosocial well-being • Quality of life • Care c/w patient preferences • Curative care vs timing of death • Patient and family satisfaction

  9. Institutional Needs • Mission and Vision (Culture) • “System” roles • Accountability patterns • Size • Scope of palliative care service • Space • ICU beds, ER capacity • Staff • Number, morale, skills (other services) • Physician relationships (alignment)

  10. Physician Needs • Practice model • Private versus staff (salaried) • Where do they practice (office vs hospitalist) • Culture • What is valued? • How is work accomplished?

  11. Detroit Receiving 300 Beds Public Level I Trauma/Emergency Wayne State University Medical School affiliate Northwestern Memorial (Chicago) 700 beds Private Level 1 Trauma/Emergency Northwestern University Medical School affiliate Compare 2 Urban Hospitals

  12. Deaths at Detroit Receiving Hospital

  13. Location of death - 1990Northwestern Memorial Hospital n = 711

  14. Needs assessment forms basis for evaluation • Cost and utilization data • Satisfaction data • Pain and symptom data

  15. Change in cost per day after palliative care service involvement:Detroit Receiving Hospital Full Support Comfort only $1,645/day $6,545/day Using TISS tool to estimate

  16. Location of death – 1995 Northwestern Memorial Hospital n = 696

  17. Implications of change in location of death at Northwestern Memorial Hospital • 50% reduction in charges / day / patient

  18. Referrals from Hematology / Oncology Physicians – Northwestern

  19. Outline • Needs Assessment • Models to meet needs • Leadership of Models • Strengths and Weaknesses • How to choose

  20. Palliative Care Hospice Therapies to modify disease Palliative Care Presentation 6m Death Therapies to relieve suffering and/or improve quality of life Bereavement Care

  21. Inpatient Unit Home care teams Consultation Services Hospital Ambulatory Home Care Teams Inpatient Units Consultation Services Hospital Ambulatory England vs USConvergent Evolution

  22. Palliative Care Inpatient Unit Consultation Home

  23. Elements Acute Palliative Care Unit Home Hospice Hospital Consultation Ambulatory Outpatient Hospice Unit Home Health Nursing Home Residential Hospice Home

  24. Outline • Needs Assessment • Models to meet needs • Leadership of Models • Strengths and Weaknesses • How to choose

  25. Leadership • Physician • Nurse • Social Work • Chaplain • Ethics • Oncology • Geriatrics • Nursing Department

  26. Outline • Needs Assessment • Models to meet needs • Leadership of Models • Strengths and Weaknesses • How to choose

  27. Outline • Needs Assessment • Models to meet needs • Leadership of Models • Strengths and Weaknesses • How to choose

  28. How to choose (where to start) • What is need? • What is possible? • What is easy? • Where does support lie?

  29. Program Exampleswww.capcmanual.info

  30. Bed Availability Beds are not available All beds occupied Patients ‘can’t get in’ Beds are available Closed units Consult Service easier Inpatient Unit Possible

  31. Mercy Health PartnersCincinnati, OH Home Hospice Hospital Consultation Home Health RN Consult

  32. Hospital Size Small Hospital Large Hospital Consult Service easier Inpatient Unit Possible

  33. Marshall HospitalSnowline Hospice, CA Hospital Consultation Home Hospice Rural Partnership RN, SW Consult

  34. Physicians Private Practice Staff Model Consultation Etiquette ‘Open’ inpatient unit Primary Care‘Closed’ inpatient unit

  35. Mt. Carmel SystemColumbus, OH 3 Acute Palliative Care Units 3 Hospital Consultation Services HomeHospice Home Health 3 Hospitals MD, RN Consults

  36. Local Culture Private Practice Traditional Collaborative Patterns Physician-led Nurse Led

  37. Allina Health SystemMinneapolis, MN Home Hospice Hospital Consultation Ambulatory Outpatient Home Health MD Consult (inpt) RN Consult (outpt)

  38. Hospice Present Absent Collaborate Home visits

  39. Carondolet Health CareTucson, AZ Hospital Education Hospice Physician Consults Home Hospice Hospice Unit

  40. Health Care Funding Fee-for-Service Global Budget Justify Services Based on Revenue Justify Services Based on Utilization

  41. Parkland HospitalDallas, TX Hospital Consultation Public Hospital >60% no insurance MD, RN, SW, Chaplain Team Ambulatory Outpatient

  42. How models chosen • Administrator interest • Clinician interest • Community pressure • Serendipity (loss) • Opportunity

  43. Mercy Health PartnersCincinnati, OH • Came out of hospital committee and a nursing administrator with interest (loss)

  44. Carondolet Health CareTucson, AZ • Hospice program desiring to go “upstream” • Focus groups describing need (Native American)

  45. Marshall HospitalSnowline Hospice, CA • Hospice desire for space in hospital • Case of a 2 yo child too ill to go home, hospice help in hospital

  46. Allina Health SystemMinneapolis, MN • Managed Care • Nurse approached MCO to negotiate outpatient visit coverage • Board of Directors listened to ethicist for inpatient consultation service

  47. Mt. Carmel SystemColumbus, OH • Outreach of hospital-based hospice/home care agency led by one administrator

  48. Parkland HospitalDallas, TX • Physician with interest • Nurse administrator (hospice background) • Case management model

  49. Summary • Many variables that influence program development • Several leadership models • Several models • Strengths and weaknesses • Select the structure that is best for you

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