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Food & Fun in San Diego

In just two short weeks nearly 2,500 attendees will be arriving in San Diego for the 2014 AAHPM & HPNA Annual Assembly. Everyone is looking forward to another year of top notch education sessions and some sunshine after a long winter. Below are suggestions for restaurants and hot spots that the locals love and can’t miss attractions for everyone.

Restaurants
Extraordinary Desserts in Little Italy
Café Coyote in Old Town
Casa Guadalajara in Old Town
Lotus Thai
A.R. Valentien – fine dining
Bandar Persian – try their amazing chicken shish kabob
Candelas Gourmet Mexican
Hexagone – French cuisine
Old Town Mexican Café
Blue Point Coastal Cuisine
The Fish Market & Top of the Market (upstairs)
McCormick & Schmick’s Seafood & Steaks
Ocean Beach
Phils BBQ
South Beach Bar & Grille
Oscars- go to the Newport Ave Location
Hodads- burgers
BO-beau Kitchen & Bar
Sushi Ota- need a reservation
Hane Sushi
Winstons fun bar with good music

Neighborhoods
Hillcrest- lively, great restaurants
Gaslamp Quarter- tons of restaurants and is easy walking from the convention center
Seaport Village- near downtown has shopping and restaurants along the bay

Other Attractions
Shopping- Fashion Valley and Las Americas Premium Outlets
Sea World
Legoland
San Diego Zoo
San Diego Zoo: Safari Park
DisneyLand
La Jolla Cove and La Jolla Children’s Pool
Whale watching- Hornblower Cruises and Flagship Cruises
Midway Museum and USS Midway the retired aircraft carrier is fascinating
Padres baseball at Petco Park
The New Children’s Museum
Coronado- there is a ferry that goes from the convention center to Coronado. Bicycle rental is available at the ferry landing on Coronado. There are also three nice restaurants near the ferry landing. Home to Hotel Del Coronado from Some Like it Hot. Check out Miguels across from the Hotel Del Coronado

For more information about everything that San Diego has to offer check out the San Diego Convention Center and the San Diego Tourism Authority.

If you have recommendations please leave them below.

Highlights of the February Issue of the Journal of Pain and Symptom Management (JPSM)

Listed below are a few articles from the most recent issue of the journal:

Web-Based Symptom Management for Women with Recurrent Ovarian Cancer: A Pilot Randomized Controlled Trial of the WRITE Symptoms Intervention
Heidi S. Donovan, Sandra E. Ward, Susan Sereika, Judith Knapp, Paula Sherwood, Catherine M. Bender, Robert P. Edwards, Margaret Fields, and Renee Ingel

Self-Reported Physical Symptoms in Intensive Care Unit (ICU) Survivors: Pilot Exploration Over Four Months Post-ICU Discharge
JiYeon Choi, Leslie A. Hoffman, Richard Schulz, Judith A. Tate, Michael P. Donahoe, Dianxu Ren, Barbara A. Given, and Paula R. Sherwood

Adequacy of Opioid Analgesic Consumption at Country, Global and Regional Levels in 2010, Its Relationship With Development Level, and Changes Compared With 2006
Béatrice Duthey and Willem Scholten

To access the articles, you must subscribe to JPSM or be a member of the American Academy of Hospice and Palliative Medicine (AAHPM). For further information on the Academy, call 847.375.4712 or visit aahpm.org.

Submitted by: David J. Casarett, MD, MA, Senior Associate Editor, JPSM

Advance Planning: More Than Care Decisions

There is much talk in health care, especially in the fields of palliative and end-of-life care about “Advance Care Planning”. And rightly so. For those with advanced illness, this process is critical to patients receiving the treatment they want and only the treatment they want. The process done well clearly improves patient’s perceived quality of life, reduces the burden of suffering, raises patient satisfaction, and also seems to reduce overall health care costs.

For a medical treatment team, whether palliative care or other, the process often needs to be focused on decisions about health care choices. Those are our immediate concern and often those concerns truly need to be addressed in the very short term such as making decisions about resuscitation with an elderly patient suffering from heart failure and pneumonia.

However, there is also a class of “patients” emerging who, while they have a diagnosis of HIV/AIDS or “terminal” cancer are not necessarily near death and, because of maintenance therapies that can often have very controllable side effects, look and feel fairly healthy. They can therefore do lots of “normal” things and lead a “normal” life. The other day I saw Magic Johnson on TV announcing he has purchased yet another sports team in LA. These people may not be so different from someone like me. I’m healthy for my age but will soon be at the age where I will be forced to begin accepting Social Security payments whether I like it or not. I clearly have a lot less of my life ahead of me than I have behind me.

In this situation, certainly the decisions we generally associate with advance care planning are critical. Under what circumstances do I want to be kept alive if I can no longer make decisions for myself and by what methods? But as I begin to seriously engage this phase of my life, I increasingly realize that there are questions that go far beyond this which, if I engage them seriously, will make all of the life I have left more complete and fulfilled. The first issue for me seems to be that if there are things I want to do or a way I want to be sometime in my life, I need to be about creating that reality for my life now. And I can create much of that reality if I plan for it. However, this planning also means re-examining some assumptions about how I have lived my life. Do I really need the “security” of a steady job and is that security coming at a price that I no longer need to or want to pay because it is keeping me from other things I want to do? How many of my possessions would I really miss if I didn’t have them anymore? Do I continue to need to own a house with the responsibility that brings or can we be free of it?

These are not simple or easy questions. I have no intention to ever retire in the normal sense. I don’t even play golf and I don’t like either Florida or Arizona. I want to cook more and maybe learn Spanish. And I want to continue my professional journey down a road I still have intense passion for.

My point in all this is that, while advance care planning in the medical context is important, it is really only a part of a larger conversation. And this is not just about a bucket list either although that can be part of it. Ideally, it should be the end product of a much longer and intricate process of deciding how you want your life to be whether you have some idea of how much longer that life will be or not.

Certainly, for us as chaplains, I think we need to be much more intentional than we have been about engaging our patients and their caregivers in these larger issues for themselves. To the extent we can help patients explore whatever these kinds of questions are for them, we will help, not only make the decisions about Advance Care Planning, but create the lives that they want for themselves and those they love.

George Handzo, BCC, CSSBB
President, Handzo Consulting
Senior Consultant, HealthCare Chaplaincy

Hospice and Palliative Medicine Visionary Eduardo Bruera Shares His Insights on the Field

In celebration of 25 years serving the profession, the American Academy of Hospice and Palliative Medicine (AAHPM) asked its 5,000 members to nominate who they think are the leaders – or Visionaries – in the field. They then asked members to vote for the top 10 among the 111 nominated.

“This program recognizes key individuals who have been critical in building and shaping our field over the past 25 years,” noted Steve R. Smith, AAHPM executive director and CEO. “These individuals represent thousands of other healthcare professionals in this country that provide quality medical care and support for those living with serious illness — each and every day.”

The Visionaries – 14 women and 16 men – are physicians, nurses and hospice pioneers such as British physician, nurse and social worker Cicely Saunders, credited with starting the modern hospice movement, and Elisabeth Kübler Ross, author of numerous books including the groundbreaking “On Death and Dying.” Five elected officials were nominated and one of them, former President Ronald Reagan, was named a Visionary for signing into law the Medicare hospice benefit in 1982.

Many of the visionaries will be sharing their thoughts about the field and who inspired their work. We’ll be posting them over the next several months. Today’s post is from Eduardo Bruera, MD FAAHPM, Professor of Medicine, The University of Texas MD Anderson Cancer Center in Houston, TX.

Who has most influenced your work and what impact has he or she had?
I was very fortunate to learn the principals and practices of whole person medicine from my father. He was a cardiologist who made home visits on a regular basis and I was able to learn a lot from his example. Dr. Neil McDonald mentored me during my early years as a fellow and junior faculty and taught me unforgettable lessons about medicine, academic and administrative issues, and demonstrated by his behavior and guidance how it is possible to be at same time an academic and administrative leader and to be a highly ethical person. Dr. Vittorio Ventafridda over the years taught me great lessons about what palliative care should be and he always insisted on the importance of taking our discipline to academic centers in the United States.

What does it mean to you to be named a “Visionary” in Hospice and Palliative Medicine?
There is no greater honor than being recognized by my peers. Over the years I have followed the teachings of our pioneers and tried to contribute to our field with research and education on how to assessment and manage common clinical problems in the delivery of palliative care. I have enormous respect for everyone working in this difficult field. In my view, palliative medicine specialists represent the essence of what medical care should be. This recognition is for me a challenge to do more and better work on their behalf.

What is your vision for the future of hospice and Palliative Medicine?
Every academic hospital and medical school will have a fully established palliative medicine department with full time palliative medicine specialists and an inpatient palliative care unit. Every hospice in the United States will have full time palliative medicine specialist medical directors and medical staff. Palliative medicine will be one of the main components of medical care, education, and research.

More information on the Visionaries project, including the list of 30 Visionaries is on the Academy’s website www.aahpm.org.

Hospice and Palliative Medicine Visionary Betty Ferrell Shares Her Insights on the Field

In celebration of 25 years serving the profession, the American Academy of Hospice and Palliative Medicine (AAHPM) asked its 5,000 members to nominate who they think are the leaders – or Visionaries – in the field. They then asked members to vote for the top 10 among the 111 nominated.

“This program recognizes key individuals who have been critical in building and shaping our field over the past 25 years,” noted Steve R. Smith, AAHPM executive director and CEO. “These individuals represent thousands of other healthcare professionals in this country that provide quality medical care and support for those living with serious illness — each and every day.”

The Visionaries – 14 women and 16 men – are physicians, nurses and hospice pioneers such as British physician, nurse and social worker Cicely Saunders, credited with starting the modern hospice movement, and Elisabeth Kübler Ross, author of numerous books including the groundbreaking “On Death and Dying.” Five elected officials were nominated and one of them, former President Ronald Reagan, was named a Visionary for signing into law the Medicare hospice benefit in 1982.

Many of the visionaries will be sharing their thoughts about the field and who inspired their work. We’ll be posting them over the next several months. Today’s post is from Betty Ferrell, PhD MA RN CHPN FAAN FPCN, Research Scientist, City of Hope National Medical Center in Duarte, CA.

Who has most influenced your work and what impact has he or she had?
My professional life has been rich with the influence of many colleagues across disciplines, some present in my daily work at City of Hope National Medical Center, and many across the globe who struggle to advance palliative care in circumstances far more challenging than my own. Over the past 14 years of our ELNEC project (End of Life Nursing Education Consortium), I have been strongly supported by many; chief among them are Rose Virani, Pam Malloy, Judy Paice, Patrick Coyne, and Kathy Foley.

My mentors have come from every discipline and I am humbled by my colleagues in medicine, nursing, chaplaincy and social work. I am confident that quality palliative care exists only when we all work together with a shared vision.

If I were to select one person who has most influenced my career it would be Nessa Coyle. I met Nessa about 25 years ago and we became cross-country colleagues and now close friends. Nessa is the embodiment of palliative care. She has the vast knowledge of pain and symptom management, the art of psychosocial support, a deep connection with both existential concerns and an intense passion and clear vision for what is right. From Nessa I have learned to remain focused on what matters, to be silent at times and to rage at others, and to remain in awe of humans facing the end of life.

What does it mean to you to be named a “Visionary” in Hospice and Palliative Medicine?
I began my career in 1977 when there were less than 10 hospices in the country, there were none in my state, the words “palliative care” didn’t exist in our vocabulary, and when Kübler-Ross work was only beginning to be known.

I count my life as one of enormous opportunity and blessing to have been a part of dedicated and passionate colleagues who have changed the culture of care and created hospice and palliative care as an essential component of health care and who have advocated for such care as a human right. I recall working closely with Diane Meier creating the National Consensus Project Guidelines, fully aware of what a tremendous gift it is to be able to do important work in the company of those you admire the most.

To be recognized as a “visionary” is a very special honor, especially having been nominated by colleagues in AAHPM. When I think “visionary” I think of those who were bold enough to see that there was a better way. I consider myself as one lone voice in a very large chorus. Advances in our field have only been possible through the generous spirit of many with a common vision that the end of life is not a medical failure, but a sacred time of life.

What is your vision for the future of hospice and Palliative Medicine?
My vision for the future is that all people facing serious illness and the end of life will have access to high quality palliative care. I hope that palliative care will be so well integrated that it would be shocking for a patient and family to not receive this care. I have heard many of my colleagues say that we who have been so privileged to be a part of this early history are building the care system we want for ourselves.

I envision a time when our society fully expects to receive “compassionate and competent palliative care” which are the words of Dame Cicely Saunders and that we have indeed built a system of care that responds to that expectation. I am confident that vision can be a reality.

More information on the Visionaries project, including the list of 30 Visionaries is on the Academy’s website www.aahpm.org.

Highlights of the January Issue of the Journal of Pain and Symptom Management (JPSM)

Listed below are a few articles from the most recent issue of the journal:

Impact of Advance Directives and a Health Care Proxy on Doctors’ Decisions: A Randomized Trial
Monica Escher, Thomas V. Perneger, Sandrine Rudaz, Pierre Dayer, and Arnaud Perrier

Use and Perceived Benefits of Complementary Therapies By Cancer Patients Receiving Conventional Treatment in Italy
Andrea Bonacchi, Lorenzo Fazzi, Alessandro Toccafondi, Maurizio Cantore, Maria Grazia Muraca, Grazia Banchelli, Mauro Panella, Francesca Focardi, Roberto Calosi, Francesco Di Costanzo, Massimo Rosselli, and Guido Miccinesi

The Effects of Cognitive Behavioral Therapy for Postcancer Fatigue on Perceived Cognitive Disabilities and Neuropsychological Test Performance
Martine M. Goedendorp, Hans Knoop, Marieke F.M. Gielissen, Constans A.H.H.V.M. Verhagen, and Gijs Bleijenberg

To access the articles, you must subscribe to JPSM or be a member of the American Academy of Hospice and Palliative Medicine (AAHPM). For further information on the Academy, call 847.375.4712 or visit aahpm.org.

Submitted by: David J. Casarett, MD, MA, Senior Associate Editor, JPSM

Hospice and Palliative Medicine Visionary Patrick Coyne Shares His Insights on the Field

In celebration of 25 years serving the profession, the American Academy of Hospice and Palliative Medicine (AAHPM) asked its 5,000 members to nominate who they think are the leaders – or Visionaries – in the field. They then asked members to vote for the top 10 among the 111 nominated.

“This program recognizes key individuals who have been critical in building and shaping our field over the past 25 years,” noted Steve R. Smith, AAHPM executive director and CEO. “These individuals represent thousands of other healthcare professionals in this country that provide quality medical care and support for those living with serious illness — each and every day.”

The Visionaries – 14 women and 16 men – are physicians, nurses and hospice pioneers such as British physician, nurse and social worker Cicely Saunders, credited with starting the modern hospice movement, and Elisabeth Kübler Ross, author of numerous books including the groundbreaking “On Death and Dying.” Five elected officials were nominated and one of them, former President Ronald Reagan, was named a Visionary for signing into law the Medicare hospice benefit in 1982.

Many of the visionaries will be sharing their thoughts about the field and who inspired their work. We’ll be posting them over the next several months. Today’s post is from Patrick Coyne, MSN APRN ACHPN FAAN, Clinical Director, Thomas Palliative Care Service, Virginia Commonwealth University Medical Center in Richmond, VA.

Who has most influenced your work and what impact has he or she had?I have been blessed in my life and career. I had wonderful parents who instilled the ability to question everything and ask “why not?” My wife Ellie and daughter Erin have been constantly supporting my love for palliative care and keeping me grounded and energized. Judy Paice has been and remains my go-to person with challenges in pain management, symptom issues and other crises. Betty Ferrell clearly took a risk on me by giving me many unique opportunities which allowed me to grow professionally and encouraged me unconditionally. Tom Smith, really to be forever known as my partner in crime, was/is a constant supporter, advocate and friend. Tom was willing to take risks with me that I believe ultimately helped us make a positive impact on countless individuals’ lives and an entire healthcare system. I have been fortunate through the years to have been surrounded by countless exceptional nurses, physicians, administrators, social workers, volunteers, researchers as well as other disciplines. Some who deserve particular attention, Bart Bobb, Clareen Wiencek, Laurie Lyckholm, Dani Noreika, Connie Dahlin , Mary Ann Hager and Ken White. All their dedication made this work easier, constantly encouraged and challenged me, and thus supported my professional development. The entire palliative care team at Virginia Commonwealth University is without a doubt the greatest group I could ever have the opportunity to work with; in a word they are” unrelenting”. Finally, our patients and their families teach and tolerate me daily, always pushing me to improve and question the status quo.

What does it mean to you to be named a “Visionary” in Hospice and Palliative Medicine? I am overwhelmed, shocked and honored. Clearly there are individuals more deserving of this honor. I believe this is a validation of the work of the teams with whom I have served, specifically Virginia Commonwealth University/Massey Cancer Palliative Care Program, the ELNEC team and the APRN palliative externship program at Virginia Commonwealth University.

What is your vision for the future of hospice and Palliative Medicine?I believe palliative care will experience extremely rapid growth and eventually acceptance within our society. This growth will be challenging as our numbers are few and the need is great. I hope programs such as our pilot APRN palliative externship program at Virginia Commonwealth University will ease this problem and promote solutions.

More information on the Visionaries project, including the list of 30 Visionaries is on the Academy’s website www.aahpm.org.

Hospice and Palliative Medicine Visionary Atul Gawande Shares His Insights on the Field

In celebration of 25 years serving the profession, the American Academy of Hospice and Palliative Medicine (AAHPM) asked its 5,000 members to nominate who they think are the leaders – or Visionaries – in the field. They then asked members to vote for the top 10 among the 111 nominated.

“This program recognizes key individuals who have been critical in building and shaping our field over the past 25 years,” noted Steve R. Smith, AAHPM executive director and CEO. “These individuals represent thousands of other healthcare professionals in this country that provide quality medical care and support for those living with serious illness — each and every day.”

The Visionaries – 14 women and 16 men – are physicians, nurses and hospice pioneers such as British physician, nurse and social worker Cicely Saunders, credited with starting the modern hospice movement, and Elisabeth Kübler Ross, author of numerous books including the groundbreaking “On Death and Dying.” Five elected officials were nominated and one of them, former President Ronald Reagan, was named a Visionary for signing into law the Medicare hospice benefit in 1982.

Many of the visionaries will be sharing their thoughts about the field and who inspired their work. We’ll be posting them over the next several months. Today’s post is from Atul Gawande, MD, Associate Professor, Brigham and Women’s Hospital in Boston, MA.

Who has most influenced your work and what impact has he or she had?
As a writer, and someone who tries to think hard about how to practically improve our systems of care, it’s been the voices of my patients and many many leaders in hospice and palliative care who have shown what better really can look like.

What does it mean to you to be named a “Visionary” in Hospice and Palliative Medicine?
It’s a bit embarrassing, really, and an exaggeration, given that I am an outsider and nonexpert in palliative medicine. But it is gratifying. I always hope I can connect and offer credible ideas, and it means a lot to know I have.

What is your vision for the future of hospice and Palliative Medicine?
It is the one I learned from your own members: that being a good clinician for those with incurable disease is to understand that sacrificing time now for the sake of possible time later can be profoundly harmful. At that point, our most important work is helping people achieve the best possible day they can today, and everyday that they may have remaining.

More information on the Visionaries project, including the list of 30 Visionaries is on the Academy’s website www.aahpm.org.

Hospice and Palliative Medicine Visionary Sister Mary Giovanni Shares Her Insights on the Field

In celebration of 25 years serving the profession, the American Academy of Hospice and Palliative Medicine (AAHPM) asked its 5,000 members to nominate who they think are the leaders – or Visionaries – in the field. They then asked members to vote for the top 10 among the 111 nominated.

“This program recognizes key individuals who have been critical in building and shaping our field over the past 25 years,” noted Steve R. Smith, AAHPM executive director and CEO. “These individuals represent thousands of other healthcare professionals in this country that provide quality medical care and support for those living with serious illness — each and every day.”

The Visionaries – 14 women and 16 men – are physicians, nurses and hospice pioneers such as British physician, nurse and social worker Cicely Saunders, credited with starting the modern hospice movement, and Elisabeth Kübler Ross, author of numerous books including the groundbreaking “On Death and Dying.” Five elected officials were nominated and one of them, former President Ronald Reagan, was named a Visionary for signing into law the Medicare hospice benefit in 1982.

Many of the visionaries will be sharing their thoughts about the field and who inspired their work. We’ll be posting them over the next several months. Today’s post is from Sister Mary Giovanni, RN, founder, president and CEO, Angela Hospice in Livonia, MI.

Who has most influenced your work and what impact has he or she had?
I see my work as following along a path that God set for me. It is a series of experiences that has led me to where I am today, humbling accepting the title “Visionary.”

Initially it was my parents who influenced me and led me to a life of service. They each had the gift of giving to others. Even my mother, while raising all 12 of us children, found time to help others. Whenever neighbors were in need – whether it was mother cooking something for them, or my father building something for them – it was just something quietly done. I feel that was where I got my gift of service.

When I began my vocation as a Felician Sister, I was working in the infirmary where we cared for ill and elderly Sisters. I couldn’t help but notice the vast difference in the way we cared for dying Sisters in the infirmary, compared to the way dying patients were cared for in a hospital setting. In the hospital, dying patients were isolated at the end of the wing, where they were treated quietly until they died. I wished that all people could have the compassionate, holistic care that we provided for the Sisters.

When I saw Dame Cicely Saunders speak in 1974, I saw the answer of how to care for the dying. I knew we needed this beautiful care for lay people here in the United States. So Dr. Saunders also had a tremendous impact on me.

What does it mean to you to be named a “Visionary” in Hospice and Palliative Medicine?
It is an honor, and also very humbling to be named a Visionary. But I feel that I really must share this honor with all of the wonderful people who have worked alongside me over these 30 years. The caring and compassion I see in my staff and our volunteers continue to inspire me to this day. And I also must credit my fellow Felician Sisters who have believed in this mission and given me the resources and opportunities needed to carry out this work.

The success of Angela Hospice has certainly been a story of cooperation, and shared passion for helping others, and I know that none of this could have happened without the help of these dedicated colleagues and friends.

What is your vision for the future of hospice and Palliative Medicine?
I think that as more families experience the benefits of these compassionate programs, we will see a better understanding of the hospice concept as a whole out in the community. This is something I’ve already noticed with young people who have seen hospice help a grandparent or other family member. They have an appreciation for the compassion and caring of this work, which I believe begins to overcome the fear.

It is understandable that people don’t want to think about death or losing a loved one. But we know that it is important that people do know about what hospice has to offer, so that when we can be of help, they won’t hesitate to make that decision.

We hear from families time and time again saying they wish they had called us sooner. We can provide so much help, relief, and comfort to our patients and their families. The sooner they call us, the sooner we are able to provide that assistance, so the patient and their families can benefit more from these services. In this way, my vision for the future is greater comfort for more patients and the people that love them.

More information on the Visionaries project, including the list of 30 Visionaries is on the Academy’s website www.aahpm.org.

Beyond Traditional Care Management

Tanya Stewart, MD FAAHPM

It’s late afternoon when you receive a call from a home health nurse about a patient you’ve known for 12 years. Mr. Jones is 70 years old with multiple chronic medical conditions contributing to four hospitalizations in six months. He was referred to home health two weeks ago as part of his hospital discharge plan for heart failure management. The home health nurse reports he hasn’t been eating well for the past two days, is unable to walk across the room without stopping to rest and is becoming more confused. His care needs are escalating, and his 76 year old wife is no longer able to manage his needs. He was referred to hospice many times in the past and each time refused. At the last hospitalization he agreed to DNR code status with limited interventions, and his primary goal is to remain as functional as possible. The home health nurse requests guidance on how to proceed.

In the traditional medical system, Mr. Jones would most likely be sent to the emergency room and again admitted to the hospital. I propose there’s a better, more innovative option that breaks this cycle:

It’s late afternoon when you receive a call from an Optum nurse practitioner (NP) to inform you that Mr. Jones has been referred to CarePlus by his health plan as part of his hospital discharge plan. The NP visits Mr. Jones in his home the day after hospital discharge and talks with him and his wife to gauge their understanding of what happened in the hospital and next steps. The NP also completes a medication reconciliation, examines Mr. Jones and reviews his goals of care. At the close of the initial visit, the Optum NP gives the patient and caregiver his/her cell phone number and specific instructions to call if they have any questions or if certain symptoms arise. After the visit, care is coordinated with the local home health team and the Optum NP’s note is faxed to your office. Four days later, the Mrs. Jones calls the NP – she is concerned about increasing incontinence. The NP arranges for a chem7, BNP and urinalysis which are drawn by the home health nurse that day. The Optum NP reassures the Joneses and schedules a home visit for the following day.

At the following day’s visit, the Optum NP notices the Mr. Jones has increased LE edema, elevated JVP, difficulty speaking in complete sentences and increased lethargy. The urinalysis returned within normal limits. The chemistry panel is unchanged from discharge but BNP is 682 pg/ml. Mrs. Jones confirms he is taking the medications as directed from the last visit.

When the NP asks about diet, Mrs. Jones says they eat a healthy diet consisting of mostly soup and vegetables. With her permission, the Optum NP looks in the fridge and cupboards and notices the patient only has high sodium canned soup and vegetables. No fresh produce is found in the house. After extensive dietary counseling and coordination with a local meals on wheels program, the NP orders a diuretic increase, home oxygen, follow-up labs and arranges daily home health nursing visits for one week. The Optum NP closes the visit with a review of Mr. Jones’ advanced care plan. The Optum NP calls your office to provide an update, and a note is faxed the next day.

Over the next few days, the home health nurse calls the Optum NP several times reporting Mr. Jones seems improved. A potassium supplement is added to address low levels on a lab draw, and the NP requests the home health nurse reinforce with both patient and caregiver the importance of staying on a low sodium diet.

The following week, the Optum NP receives a distressed call from Mrs. Jones. Her husband is struggling to breathe, is again confused and unable to walk from his bed to bathroom. The NP makes an urgent visit and during the history review, Mrs. Jones admits she had high sodium take-out food delivered to the home the night prior at her husband’s request. After a complete assessment, the Optum NP confirms a diagnosis of heart failure exacerbation caused by dietary indiscretion. She implements a home hospitalization and administers intramuscular Lasix on two consecutive days and draws chem7 and BNP. Throughout the course of the acute event, the Optum NP calls your office to collaborate on the patient’s care and provide real-time updates.

On day three, Mr. Jones’ weight is down, but he is too weak to ambulate or complete any ADLs. His wife is fatigued and had a fall the previous evening when trying to help him to the bedside commode. Although he was adamantly against getting care at a skilled nursing facility (SNF), he agrees this may be necessary so he can gain strength to return home. The Optum NP arranges a direct admission to the neighboring nursing home for skilled care after speaking to the house physician and SNF admission coordinator. The Optum NP sends all notes from the Optum electronic medical record with the patient, calls your office to clarify your desire to follow the patient at the SNF or have the house doctor follow, and communicates the care plan changes with the health plan and home health agency.

During the skilled stay, the Optum NP sees Mr. Jones regularly, along with the attending physician. During one of the visits, the Optum NP reviews the goals of care. Mr. Jones recognizes he is tired of being so sick and is not living the quality of life he imagined. He requests his Physician Order for Life Sustaining Treatment be changed to comfort measures and hospitalize only if symptoms cannot be controlled at home. The Optum NP offers hospice, but he and wife again decline.

After regaining strength and the ability to complete his ADLs, Mr. Jones returns home. Over the course of the next six months he is treated by the Optum NP for a urinary infection, community acquired pneumonia and cellulitis. He does not have any additional hospitalizations during this time. During the holidays the Jones’ daughter visits from out of state for the first time in two years. She raises concerns about her father’s decreased strength, weight loss, confusion and instability with transfers. The Optum NP holds a family meeting and a decision is made for Mr. Jones to enroll in a hospice program.

As you can see, CarePlus goes beyond traditional care management programs. Providers deliver hands-on care to members at home and, if necessary, treat them. By doing so, CarePlus helps individuals avoid unnecessary hospitalizations and emergency room visits, reducing costs and improving quality. Throughout the relationship, CarePlus coordinates and delivers compassionate, hands-on care to individuals while providing ongoing care coordination with their primary care provider.

Do you serve in a more traditional system and see how such a model could benefit your patients? Do you work in a program like CarePlus, but with a different approach that’s achieving similar results?

Dr. Stewart works for Complex Population Management in Oregon and as the medical director for Community Home Health and Hospice in Longview, WA.

This post previews the latest installment of AAHPM’s Hospice and Palliative Medicine Profiles in Innovation.

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