Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Embedding...

Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only.

Embedding Palliative Care in the Oncology Clinic: Culture, Infrastructure, and Growth

Wednesday, June 12th , 2013Audio Conference

1:00 - 2:00 PM EASTERN

Vicki Jackson MD,MPHChief, Division of Palliative CareMGH, Department of MedicineHarvard Medical SchoolBoston, [email protected]

Simone Rinaldi MSN, ANP-BC, ACHPNCo-Director, Outpatient Palliative Care ClinicMGH, Department of MedicineBoston, [email protected]

Mihir Kamdar, MDCo-Director, Outpatient Palliative Care ClinicMGH, Departments of Medicine and Anesthesia Pain; Harvard Medical School; Boston, [email protected]


DISCLOSURE

• No Industry or Financial Disclosures

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Building the Plane as We Flew It:

Our Story at MGH

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A History of MGHOutpatient Palliative Care

• Began in 2003• No designated office space• Appts. scheduled according to patient availability

(when seeing their oncologist)• PC availability key factor in building relationships• Staffed by 1 MD and 1 NP • ½ day on 2x/week with 2-3 visits/week• No financial arrangement with oncology

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MGH Outpatient Palliative CareTen Years Later

• Volume increased 400 % over past 5 years• Annually

– 900 New Consults – 2400 Follow up visits

• 5 MD, 2 NPs, and an Access RN– Covering 14 sessions

• MD and NP Fellow Education• Medicine Residents• Visiting Observers• Expanding research agenda

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How Our Plane Lookedin the Beginning...

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How We Want it to Look...

We’re getting there, but we’ve had to learn to embrace the turbulence!

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• Scope of an Embedded Practice– Who Do We See, Where and How We See

Them• The Challenges of Scheduling• Access and Referral Management• Building and Maintaining Relationships with

Referrers• Lessons Learned & Cases

Outline of Today’s Audio Conference

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Defining Your Patient Population

History Who Do We See?

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Who Do We See at MGH?

• Primarily Cancer Patients 95%• Occasional Non-Cancer Patients 5%

– CHF– ESLD– ESRD– ALS– Geriatric Pts with Multiple Co-Morbidities

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But Where/How You Embed May Depend on Your Institutions Needs

• The Environmental Scan of your site:Clinical Needs

Choose populations with high symptom burden and high resource utilization Are there clinical groups with influence who want integration? Start there!

Financial Opportunities For example, oncology was very supportive at MGH and was willing to split the

losses for 2 years while the clinic got up and runningEducational Needs

To have an ACGME accredited fellowship must have a clinicResearch Agendas

Having an oncologist interested in studying palliative care facilitated integration at MGH

Institutional/Health System Goals Decreasing re-admissions and length stay

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Where It Can Get a Little Sticky...

• Non-Cancer Pain• Cured but with Post-Treatment Pain• Patients with Substance Abuse Issues

• Must think through…• Does our team have the expertise?

• If not, who to partner with?• How do we want to be defined?

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Identifying the Ideal Model

How Do We See Them?

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Palliative Care Across the Continuum

Primary Palliative Care• Essential PC skills

• Support that all providers should have at their disposal to care for challenging patients

e.g. Education for all clinical providersSome community based palliative care models

Secondary Palliative CareConsultative only role with referring clinician

e.g. One time consultation with follow up as needed

Tertiary Palliative CareCo-Management with referring clinician

e.g. Follow patient closely in all sites of care delivery

Quaternary Palliative CarePC assumes full care of patient

e.g. Inpatient hospice, Inpatient Palliative Care Unit

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Think About Your Model of Care

• At MGH: Co-Management Model• Rare Exceptions-> Consultative Model• How Do You Want to Operate Your Clinic?• What are Your Available Resources?

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Issues of Space and Scheduling

Where Do We See Them?

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Where Do We See Our Patients?Anywhere We Can Find Them!

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Defining Your Visit Parameters

• Number of New and Follow-up Patients per Clinic Session?

– A session is 6 patients with 2 new and4 follow-up visits

– High no show rates…do you want to overbook? • Time Allotment for New and Follow-up Visits?

– New 60 minutes– Follow up 30 minutes

• Number of Clinic Sessions per FTE?

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• Frequency of Follow-Up Visits• Opportunities for Joint Visits• Visits in Infusion or Other Sites

Defining Your Visit Parameters

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The Complexities of Scheduling in an Embedded

Clinic

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Models of Embedded Scheduling

• Linked => PC visit at the same time as Oncology• Better utilization• More complicated, not always efficient• Compromises continuity with PC provider• Improves communication between referrer and oncology

– Joint visits are possible

• Unlinked => PC patients scheduled separately • High no show rate• Easier Scheduling• Better if limited number of Providers

• Mixed Model => Separate Scheduling with urgent consults seen on same day

• Newly developing programs often do this as part of marketing

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The Challenges of Embedded Scheduling

–Linking of Visits•Advantages and Complexity

–Benefits of a Dedicated Scheduler •This is Not Straightforward - Must be skilled!•How comfortable is the person with talking about PC?

– Must be educated in PC and be able to explain it to patients and families

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Optimizing Access and Utilization

“If You Build It, They Will Come”

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Optimizing Access: Referral Management

–Varying Models of Referrals Management–Currently Utilize Centralized Mailbox–Importance of:

•Clear Reason for Referral•Denoting Urgency•Asking if Patient is Aware

–Managing Requests for Same Day Visits

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–Daytime Phone Call Management–After Hours Calls–Email/Internet Communication?

Optimizing Access: Patient - Provider Communication

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Optimizing Utilization

• Challenges of Linked Visits – Dependent on oncology schedule

• Late providers• Cancellation of chemotherapy

• Phone-Based Visit Reminders• RN Access Nurse Pre-Visit Calls• Effective Urgent Triage can Help Utilization

when Needed

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Thinking About the Details

The Nitty Gritty

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Think About Who Will Handle:

Scheduling Medical Assistants, Billing Specialists Prior Authorizations Script Refills Medication Administration in Clinic Day Time Calls After Hour Calls

*Define these with your institution ahead of time...

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Metrics and Outcomes

It Always Comes Down to Numbers

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The Importance of Gathering Metrics

• Identify Gaps in Clinic• Better Sense of Needs when Dealing with Leadership• Sample Metrics:

– Access: Goal of <14 days– Utilization Rates– Symptom Scores: VAS etc.– Patient Satisfaction and Referrer Satisfaction

• Building Data Collection Infrastructure Early • -> Better for Your Clinic

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You have a clinic…now what?

Relationships with Oncology:How to Start And Nurture

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We must define early integrated Palliative Care

Palliative Care

Diagnosis Active Therapy Dying Bereavement

Hospice

What is this care?

Disease Modifying Therapy

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Early palliative care differs from inpatient consultation

• Focus is on developing long-term relationships• More time to address difficult topics• Less often in crisis• Promotion of quality of life throughout the course of

the illness • Care has the potential to be nebulous• Care is collaborative with oncology team

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Cultures

• Most oncologists value this work and many like doing it themselves– We must remember that when we are entering their

world– How can we be of help?– They must learn how we do this work

• Joint visits are very helpful to begin to understand the culture.– We must learn how they do this work

• PC in oncology must know basic oncology– Take time to learn it

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CollaborationWho does what?

• Early in the integration must have explicit discussion with each provider– How can I be helpful to you in the care of this patient? – Do you want me to make recommendations to you about

med changes or to prescribe myself?– How do you feel about me talking about prognosis if a

patient asks?– How shall I communicate with you after I see the patient?

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Many opportunities for miscommunication

• Patients tell us different things– We don’t hold the key to chemotherapy– They don’t want to disappoint their oncologist– We ask differently

• What was the patient really told?– Develop a differential diagnosis for this

discrepancy– Hold oncologist in high regard

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Building a referral base

• Attend regular clinical meetings e.g. lung and GI cancer

• If clinic is light, go visiting oncologists…– “Oh, hey, I have a patient in my office that I think

might be good for you to see…”• Offer to see the patient together

• Keep your door open…– “I have this tough patient, can I talk to you about

them? Not sure what to do…”

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Triggers can help build a clinic

• Many times oncologists may be open to PC involvement but have not made it a routine part of care– Are there populations that oncology would agree

should see palliative care?• Pancreatic and lung cancer

– If all agree to this for certain patient populations, then could start as part of the team from diagnosis

• Research data supports this model

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Lessons Learned Over the Past Decade

“If We’d Known ThenWhat We Know Now….”

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Outpatient PC interacts with Inpatient PC….

• Must think about the outpatient team interacts with the inpatient team– Managing continuity– How do the two teams communicate and track

patients?

• Outpatient will drive up inpatient volume– Do you have staffing to accommodate?

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Lessons Learned

• We are not only serving the patients but very much serving the referrers

• Learn basic oncology• Must be more skilled in symptom management than

those referring to you• Be flexible• Hold them in high regard

– Being an oncologist is hard• Develop a method for communication about challenges

– Expect them they will happen

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Question & Answer Period

Thank you for joining us today!

ABOUT CAPC

The Center to Advance Palliative Care (CAPC) provides health care professionals with the tools, training and technical assistance necessary to start and sustain successful palliative care programs in hospitals and other health care settings. CAPC is a national organization dedicated to increasing the availability of quality palliative care services for people facing serious illness.

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Continue the Discussion on CAPCconnectTM Forum!

At the conclusion of this audio conference, we welcome you to continue the discussion with your peers and faculty on CAPCconnectTM Forum!

Go to: http://www.capc.org/forums to post your message and comments within the

“Palliative Care Outpatient Services” discussion topic!

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http://www.capc.org/forums

Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Embedding...

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