Provide the right care for each patient at the right time in the right care settingTransitions in Care:

Caring for our PatientsConnecting our Partners

Transitions in Care:Caring for our Patients

Connecting our Partners

Jane Pike-BentonExecutive Vice President Home Health & Care Transitions

Multi-disciplinary approach to shift the culture of our acute care facilities regarding serious illness and end of life care

Palliative Care Program - Mission

Fall 2009 STAAR Team record review of readmitted HF

patients reveals multiple patients with chronic HF and end of life concerns.

Our Journey

May 2010 MetroWest Medical Center Ethics Committee

ask MetroWest HomeCare & Hospice to collaborate to develop an Inpatient Palliative Care Program August 2010

Saint Vincent Hospital and MetroWest HomeCare & Hospice team up to create a cross-continuum Inpatient Palliative Care Program

Feb 2011 Inpatient Palliative Care Program begins

consults at MWMC

Our Journey

April 2011o Inpatient Palliative Care Program begins

consults at SVH

Palliative Care Steering Committee approves policies & procedures, physician

order sets and drives the cultural shift through education

Palliative Care Consult Team meets with patients, family members and

health care team members to discuss patient wishes and options

Palliative Care Program Structure

Important to align the Palliative Care Program with the Ethics Committee, Cancer Care Center, Intensive Care, Emergency Department, Physicians, Hospitalists, Nursing and Chaplaincy, as well as other care team members

Palliative Care Program Structure

Additional Responsibilities

o Policies and Procedureso Physician Order Seto Education at Physician, Nursing and

Administrative Meetingso Schwartz Roundso Palliative Care Informational Fairs

ResourcesIntroduced in 1997 with funding from a grant from the Robert Wood Johnson Foundation

Changes the way we talk about and plan for care at the end of life

Simple to use

Available in 15 languages

Can also be completed on line

Enhance pain and symptom management Care concordant with patient-family

preferences Improved patient and family satisfaction Reduced costs via shorter length of stay,

decreased readmissions and less acute treatment ordering

Earlier transition of care to Bridge or Hospice care

Hospital – Hospice Partnerships in Palliative Care Benefits as per NHPCO

Patients who are discharged savings- $1696

Patients who die in the hospital savings - $4900

Decreased readmission rate of patients with chronic and/or end of life illnessMorrison et al published an article in The Archives of Internal Medicine

2008;168(16):1783-1790. “Cost Savings Associated with US Hospital Palliative Care Consultation Programs”

Other Potential Benefits

Palliative Care Outcomes

169 consults completed in the first 7 months

169 consults completed in the first 7 months

Many patients with chronic illness unrelated to cancer

Many patients with chronic illness unrelated to cancer

37% of patients were admitted from Skilled Nursing Facilities

It’s about how you live

Center for Advancement of Palliative Carewww.capc.orgResource for tools, articles, templates for policies and procedures

Resources

Five Wisheswww.agingwithdignity.org

NHPCO-National Hospice & Palliative Care Organizationwww.nhpco.org

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Discussion & Reflection