Transcript Document

Collaborating Hospice
Relationships
Martha L. Twaddle MD, FACP, FAAHPM
Chief Medical Officer, Midwest Palliative & Hospice CareCenter
Associate Professor of Medicine
Rush University; School of Medicine
Program Director of Palliative Care
Rush Medical College
Past President, The American Academy of Hospice
and Palliative Medicine
Steering Committee, The National Consensus Project
in Palliative Care
www.capc.org
What we’ll cover together…
• Using case examples – let’s discuss
concepts and opportunities for hospice
programs to collaborate with institutions
such as hospitals, LTC, ALF, and with
other community organizations.
www.capc.org
Necessary:
• Appreciation of the well established
interdisciplinary model within hospice
care.
• Appreciation of the culture and values of
each entity – can be drilled down to
specific institutions
• Appreciation that together care can be
fuller, more effective, robust, and
satisfying for all parties.
www.capc.org
The Epiphany
• Progressive hospices have accepted the
challenge of leveraging what we know
how to do: interdisciplinary palliative care
services (or whatever term you prefer) for
a patient population whose
needs/preferences extend beyond the
boundaries imposed by the Medicare
Hospice Benefit.
www.capc.org
www.capc.org
Scherer
Gertrude
• 86 yo widow living independently in small
town in central Illinois
• Daughter, 53, lives local to the CareCenter
and calls looking for “help with my
mother.”
• No known terminal diagnosis, no pressing
medical issues.
• Just a very concerned daughter…
www.capc.org
Gertrude
• The daughter meets with a Palliative Care
Consultant to talk about issues regarding
• caring for an aging parent,
• the family’s role in Advance Care Planning,
• supportive options available in the community.
• Daughter moves her mother to the area, into an
ALF. Obtains a formal Palliative Care
Consultation to see her mother.
www.capc.org
Background…
• This visit is not covered by insurance –
out of pocket consultation expense for the
daughter
• Scheduled and processed like a patient
visit – notes created, can copy family if
appropriate.
www.capc.org
Gertrude
• Over the subsequent year, Gertrude
becomes much more frail, afflicted by GI
blood loss, recurrent anemia, anorexia,
and fatigue.
• She declines a medical work-up and
consistently preferences that she does not
wish to have further hospitalizations.
• She falls, and fractures her hip and is
hospitalized for emergent repair.
www.capc.org
Gertrude
• The Palliative Care inpatient service at the
local hospital is staffed by the Midwest
CareCenter physicians – an inpatient visit
is provided to Gertrude.
• The PC team helps negotiate the goals of
care with the hospital team
• The PC team works with her doctors and
family to facilitate Gertrude’s transfer to a
LTC facility for post-op rehabilitation
(skilled care) s/p hip repair.
www.capc.org
Background…
• The Palliative Care inpatient service is already
involved with Gertrude in the outpatient setting
– so here does not require a new consultation
request,
• billed as co-management,
• if a group practice – billed as an established patient.
• If this was the first meeting – a consult order
from the attending physician is preferred –
remember the four R’s of consult –
Request
Render
www.capc.org
Reason
Report
Background…
• The patient and family can request Palliative
Care as a “second opinion” without a
consultation order.
• Politically can be “sticky” but may be in
patient/family best interest.
• Provide reason and report as though a consult
www.capc.org
Gertrude
• Gertrude cannot achieve the necessary rehab
goals in the skilled unit and opts out of “skilled
care” into the nursing home room & board.
• Guess what!!!? The Midwest Palliative
CareCenter physicians “staff” the consult team
at this LTC facility and see Gertrude in follow-up.
• The team facilitates discussions with Gertrude,
her principle physician and family and Gertrude
elects to enter hospice care.
www.capc.org
Background…
• Documentation of choice is necessary.
• The patient/family and attending physician
choose which agency will be utilized for hospice
care – it is not an “automatic” referral to
Midwest.
• Hospice programs can consider following
via their PC consults arm a patient in
another hospice program;
• requires a contract arrangement with the
other hospice.
www.capc.org
Midwest is everywhere!
How did we get to be that way?
 In 1989 – we had 4
hospice patients
 We practiced B&B
hospice
 And defined ourselves by
what we “don’t do”….
www.capc.org
We asked people to wait!
“finish your treatments first…”
The Collegial perspective of
our referring physicians…
• High association
with imminent
death
• “Consults” were
primarily new
referrals to hospice
• High association
with MSO4 and
Ativan
www.capc.org
We were the first to ask
ourselves…why do we wait?
Why is that we wait until
death is imminent or, at the
very least, obvious, to talk
about quality of life and the
goals of care???!
www.capc.org
Health Status
Steady Decline, Short
“Terminal Phase”
Decline
Death
www.capc.org
Time
The Bumpy road of Life’s
final phases…
Health Status
HOW
‘BOUT
NOW?
Decline
Time for
Hospice
Referral?
Crisis
Death
www.capc.org
Time
Process changing
realizations!
The expertise of hospice care is needed, necessary, and
vital far upstream to the actual hospice referral.
The customer wants our support and expertise,
even when they “don’t want hospice”
We can tailor our support to meet the
needs of patients and families and meet
them where they are…
www.capc.org
Our awakening spurred our
Growth and Activity
• 1989 – Community-based not-for-profit
Hospice program serving 4 pts
• 1995 – Opened our first Hospice IPU and
launched a consult service model after the
successful Rehab Medicine model
• 1998 – launched a home-based Palliative
Consult service
• 1999 – moved our IPU and expanded our
consult service to another (and
competitor) hospital system
www.capc.org
Our awakening spurred our
Growth and Activity
• 2001 – opened an ambulatory PC
consult practice
• 2003 – evolved a PC consult service
in a LTC facility
• 2005 – mourned the death of our
first LTC service and grew others
• 2005 – leased space in an Oncology
practice for PC consults
www.capc.org
Our awakening spurred our
Growth and Activity
• 2006 – we find ourselves
increasingly providing specialty
services to multiple competing
entities.
www.capc.org
Behind the scenes of every
project:
• Understanding the needs and culture of
the “customer”
• Each institution is unique
• Complementing/enhancing their system of
care delivery through collaboration
• Educating and training “their own” to be a
part of our team.
www.capc.org
A Model: Our Growth and
Activity
• Commitment to remain community-based and
mission focused
• Seek to collaborate and respond to requests to
create innovative service models in many
different settings
• Remain community-based and mission
focused
• Serving competitive systems in the community!
• Tailor our services to meet the needs of each
institution – that is “one size does not fit all…”
www.capc.org
Hospice Team Transformation
• Every consult is an opportunity to identify
support needs and answers.
• Bring the expertise of the IDT approach, whole
person perspective, and experience with
prognosis to the acute care and long-term care
setting.
• Increase advocacy for patients and families and
colleagues: “your options are……”
• Think outside the box!
www.capc.org
Introducing Palliative Care
Support early
• As a quality initiative for improved symptom
control
• As a platform for Advance Care planning
• As navigators in the complex world of
healthcare where medical goals may be
discordant with meaningful outcomes
• Not just for the sake of the hospice
referral – creating robust support systems
upstream from “end-of-life”
www.capc.org
Our Definition of Palliative
Care
“Interdisciplinary
care that aims to
relieve suffering and improve
quality of life at any age, at any
stage and in any setting, whether
the goal is cure or care.”
www.capc.org
Our Target audience
• Those with a recent or recurrent diagnosis of
a life-threatening illness
• Those with chronic illness facing increasing
debility, life-limitation, and life change
• The frail elderly and their families/caregivers
strategizing the “what if...”
• The families and caregivers of the above….
www.capc.org
What are the goals of the Palliative
Care Team?
• Focusing on relief of suffering, promotion of
function, clarification of goals of care, and
support for patient and family caregivers; aims
for best possible quality of life as determined by
patient and family
• Complementing the healthcare teams in place
in whatever setting the patient may be at any
one time
• Following the patient/family across many
settings of care and in/out of many
institutions if necessary.
www.capc.org
Collaborating Hospice
Partnerships
• Provide opportunities for hospices
and healthcare institutions to fully
utilize the strengths and
resources of each other to
benefit patients & families!
www.capc.org
Our Hospital – Hospice teams
• Rush North Shore Medical Center
• Evanston Northwestern Healthcare
• Evanston Hospital
• Glenbrook Hospital
• Highland Park Hospital
• Lake Forest Hospital
• St. Francis Hospital
www.capc.org
LTC/ALF Teams
• Contracts with over 150 LTC and ALF facilities
• Three have robust Palliative Care and Hospice
services of 15 to 30 patients
• Regular “rounds” provide real time teamwork,
education, and enhanced communication
• Settings host regular community and staff
educational events as well as on-site
bereavement support and memorial services
www.capc.org
The “Consult” starts the
conversations • For any setting – the how of the
“consult”…
• Patient, physician or family initiated
• Any patient, any diagnosis, any age
 not driven by prognosis –
but by perceived need.
• Any location
•
•
•
•
Hospital
SNF, ALF
Community or ambulatory clinic
Home
www.capc.org
Palliative Care Consult
Team
A Fluid Interdisciplinary Team Model
Hospice and Institution’s staff create the team:
• Hospital – ward staff, pharmacist, hospital
chaplains and SW + PC practitioners
• LTC – ward staff, SW, PT, OT + PC practitioners
• ALF – RNs of ALF + PC practitioners, LCSW +/home health
• Office setting – our practitioners and LCSWs
www.capc.org
Palliative Care Consult
Team
• In addition to clinical care, goals of:
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
www.capc.org
Documentation
• Your notes say a lot of who you are
• Document using the Domains of Quality
Palliative Care
(NationalConsensusProject.org)
www.capc.org
Our notes are formatted in
the domains…
• Impression:
• Recommendations:
•
•
•
•
•
•
•
•
Process of Care
Physical Aspects of Care
Psychological Aspects of Care
Social Aspects of Care
Cultural Aspects of Care
Spiritual Aspects of Care
Care of the Imminently Dying inserted when applicable
Ethical/Legal Aspects of Care
• F/U in: who, how, and why
www.capc.org
Total Program Staffing
for Palliative Care Consults 06
• Palliative Care Physicians
• Full-Time MD and part-time MDs
• 13 MDs associated with the service – small
groups rotate in the different settings
• 1 Nurse Practitioner – we need more!
• Social Worker(s)
• Hospital Liaison RN
• Practice Manager
• Practice RN = Care Manager,
• Office staff – Scheduler, Coder
www.capc.org
Claire
• 52 yo breast cancer survivor
• Active in Cancer Wellness Center support
groups and healthy living activities
• LCSW at CWC notes that Claire’s PPS is
decreasing (was 90, now 70)
• Suggests to Claire to consider a formal
Palliative Care Consultation
www.capc.org
Palliative Performance Scale
PPS level
Ambltn
Activity & Evid of Dis
Self care
Intake
Conscious
100%
full
nml, no evid of dis
full
nml
full
90%
full
nml, some evid of dis
full
nml
full
80%
full
nml act with effort
full
nml/reduced
full
70%
reduced
unable nml work, signif dis
full
nml/reduced
full or conf
60%
reduced
unable hobby, housewk
occ ass
nml/reduced
full or conf
50%
sit/lie
unable to do any wk;ext disease
much asst
nml/reduced
full/drowsy/conf
40%
bed
unable to do most activity
mainly asst
nml/reduced
full/drowsy/conf
30%
total bed
unable to do any activity
total care
nml/reduced
full/drowsy/conf
20%
total bed
unable to do any activity
total care
min to sips
full/drowsy/conf
10%
total bed
unable to do any activity
total care
min to sips
drowsy or coma
0%
death
www.capc.org
Claire
• Calls Midwest to arrange outpatient visit.
• Midwest calls Oncologist for “an order”
• Oncologist expresses shock – “She doesn’t
need hospice!”
• Midwest describes the difference
• Claire sees Palliative Care practitioner in
office setting
www.capc.org
Claire & PCC
• Discuss and establish greater clarity around Claire’s
goals
• Coordinate with CWC (Wellness IDT) to facilitate a plan
of care that integrates with community programs for
exercise, massage, and individual psychology work
• Continue intermittent care for over 2 years, through
several treatment courses for the breast cancer
• Claire actually enters and leaves hospice care during this
2 year period – gets better during her time in hospice,
• Then reenters hospice again approximately 8 weeks
before her death.
www.capc.org
www.capc.org
Althea
• 84 yo widowed lady diagnosed with colon
cancer moves in with her son and his
family
• Enters hospice care given diagnosis and
communication of poor prognosis
• Hospice home care continues for several
months
www.capc.org
Althea
• Despite diagnosis – Althea is “doing fine”
• Her son’s family is not…
• Family meeting (many) facilitates transition of
Althea to neighborhood nursing home
• Althea thrives in the social environment, gains
weight, becomes increasingly active
• “graduates” from hospice and lives 2 more
years!!!
• Seen intermittently with PCC in the NH
www.capc.org
Opportunities for ongoing
care
• In the “old days” – a hospice discharge or
revocation meant “good-bye for now”
• Today we have capacity to continue to
support patients/families without the
limitations of only one programmatic
structure
www.capc.org
Challenges within these
opportunities
• We must think beyond one
programmatic structure
• We must honor the regulatory milieu
of many programmatic structures and
how to move correctly effectively
between them
• We must be overt in our support of
patient/family choice
www.capc.org
Where do I start?
www.capc.org
How to Make it Happen
1.
2.
3.
4.
5.
6.
Build on Established Relationships
Get sound legal advice
Recognize and address internal resistance
Use Education as a powerful tool for change
Make it easy to bill appropriately for services
Anticipate growth
www.capc.org
1.
Build on Existing
Relationships
• Leverage the earned credibility hospice
programs have established in the
community; this is a key resource in
developing partner relationships
• Assure that hospice physician and nurse
leadership have the skills, credibility and
visibility to elicit referrals
www.capc.org
1.
Build on Existing
Relationships (continued)
•
Focus on helping referral sources with THEIR
patients
Deliver quality services in a timely manner
Document Outcomes
•
•
- to create a record of accomplishment
- to serve as benchmarks for peer assessment
- to create a baseline for quality assurance
initiatives
- to justify funding support
www.capc.org
2. Get Sound Legal Advice
• Be aware that each State has its own unique set
of legal and regulatory requirements
e.g. see all State list of corporate practice of
medicine laws (tool)
• There are alternative organizational structures
within which professional health care services
can be rendered
e.g. see Raffa legal opinion (tool)
• Health Care Attorneys are specialists – you need
one.
www.capc.org
2.
Get Sound Legal Advice
(continued)
• Use contracts to define who will provide what
services and how
- e.g. MD and RN’s to Consult Sx
- e.g. leased space for a Hospice IPU
• Use contracts to define how services get
reimbused
- e.g. XRT
- e.g. invasive pain management
- e.g. dietary and housekeeping for IPU
www.capc.org
2.
Get Sound Legal Advice
(continued)
• Make sure contracts are REGULARLY
reviewed and updated
www.capc.org
3.
Recognize the Barrier of
Internal Resistance
• While hospitals and hospices are both in the
business of healthcare, providers and
administrators from each setting bring different
skills and perceptions to the table
• Creating a climate of collaboration takes time: it
is a process and not an event
• For early initiatives, involve individuals from
each setting who can focus on the desired
outcomes and who are amenable to change.
www.capc.org
4. Use Education as a
Powerful tool for change
• Integrate with or join the faculty at are teaching
institutions
• Develop formal curriculum for the disciplines of
medicine, nursing, social work etc and open
your doors to students
• Provide regular educational sessions in
institutional settings via Grand Rounds, Noon
Conference, Specialty rounds, Inservices, etc.
www.capc.org
5. Bill for Services
• Understand that Part B billing is very different than
billing for Medicare Hospice services
• Determine if your organization can/should assume Part
B billing or if that function is to be subcontracted (a
“make” or “buy” decision)
• Make it easy for physicians and nurse practitioners to
bill (see tool);
• Provide coding information (Charles)
• Bill from the beginning – do not delay this aspect of the
work
• Track the financial data – for business reasons and to
justify new, on-going and/or enhanced funding support
www.capc.org
6. Anticipate Growth
• Assume several different utilization projections
and use them to test different staffing scenarios
• Identify and monitor referral data patterns
• Create staffing flexibility by developing position
descriptions identifying cross-program and/or
cross-provider functions
- e.g. liaison nurse (see position description)
• Identify or develop access to per diem services
- e.g. PCCHNS Private Care, Inc.
www.capc.org
Where has this journey taken
us?
www.capc.org
“You must be
the change you
wish to see in
the world”
MK Gandhi
www.capc.org
[email protected]
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