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A Fresh Look at End-of-Life Care

Joe Cantlupe, for HealthLeaders Media, September 13, 2013
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Terminology aside, many hospitals are expanding the scope of their palliative care programs. Some, such as the Vanderbilt University Medical Center in Nashville, are expanding programs beyond primary care to other service lines, including oncology and cardiology.

The 325-bed Gundersen Health System in La Crosse, Wis., extends palliative care to outpatient services, while inside the hospitals, its hospitalists are becoming more involved in leadership of palliative care programs. Citing a need to improve patient and family education about palliative care, hospitals are tapping into educational programs and using tools such as videos to increase awareness about end-of-life care.

Less than a decade ago, hospitals were just scratching the surface on developing palliative care programs. Yagnesh Patel, MD, vice president of medical staff at Chandler Regional and Mercy Gilbert Medical Centers in Chandler, Ariz., recalls in 2004 when the hospital's former CEO "asked the group who knows anything about palliative care."

One hospital official "chimes in, I know a little bit." The CEO responded, "You are it," meaning he should direct the program. That set in motion a small palliative care program for Chandler Regional. When Mercy Gilbert Medical Center was built in 2007, it also started a palliative care program. The hospitals have a joint palliative care program that includes inpatient beds and a staff of 11.

Over the past several years, the number of inpatient visits for the hospitals' palliative care programs increased steadily, from 2,800 in 2009 to 3,212 in 2012, and also now averages 52 referrals a month to the outpatient palliative care program, Patel says. By coordinating the palliative care and hospice program, the hospitals also have reduced readmission rates. The palliative care readmissions rate was listed at 1.5%, compared to the overall hospital rate of up to 10%, he adds.

A growing elderly population in Arizona and a lengthy list of congestive heart failure and cancer patients prompted the hospitals to begin their palliative care specialty. Before the palliative care programs were launched, there "was a lack of symptom management and support was lacking," Patel says. "There wasn't enough advocacy for patients' needs, and it wasn't addressed in the acute care setting. As a result, the patients ended up back in the hospital.

"We believed it was necessary to enhance the transition between hospital and home, and we developed an outpatient program two years ago. Once we began our focus on palliative care instead of end-of-life, community hospices came to us and asked how they could support our endeavor to help this special population who were falling through the cracks." Patel says medication reconciliation and illness education are key components of any hospital's plan to reduce readmissions.

Integrated programs

"It's time consuming when you are doing it," Timothy Corbin, MD, medical director for hospice and palliative care services at Scripps Health, says of palliative care. "In a hospital when you are in crisis mode and there's a sudden change in someone's health status, everybody is scrambling, but palliative care needs time. The patient doesn't always hear what's being told and you have to take the time to have these conversations."

That's why it's important to have an integrated program that involves hospitals, medical groups, and home- and community-based services, especially for patients with late-stage chronic illness, says Brad Stuart, MD, CMO at Sutter Care at Home, which is part of the 24 hospitals and more than 5,000 physicians affiliated with the Sutter Health system based in Sacramento, Calif.

Sutter has included care management and palliative services under the umbrella of the Advanced Illness Management program that Stuart and his team created for what he terms a "vulnerable and growing population." While palliative care is often focused on the "relief of symptoms and suffering," Stuart says, "our focus is much more comprehensive and positive."

Multidisciplinary teams that include physicians, nurses, social workers, therapists, and nutritionists are part of Sutter's palliative care program. Various elements focus on the specific needs—and wants—of patients. While physicians often outline the medication needs for patients, the AIM program always considers "what does the patient want?" Stuart says. It's the "little things" that matter that are too often lost in traditional medical care, he adds.

"We are taking more seriously those little things that a patient wants or needs," Stuart says. "It's like the patient walking to the dinner table with their family, or seeing a granddaughter graduate from high school. We make those personal goals the priority and then design care plans to match those. That causes a very interesting shift in priorities, not only for the care team but for people being cared for."

To develop its AIM program, Sutter received $13 million from the Center for Medicare & Medicaid Innovation under a three-year grant. The money came after Sutter's Sacramento region showed positive outcomes from its AIM program, such as reduced hospitalizations and improved care transitions.

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