Profile in Innovation

Leveraging Technology to Improve Patient Monitoring

Submitted by Rebecca Collins RN, BSN, OCN, CHPN

Hospice has long been seen as a way to provide comfort through effective symptom management for terminally ill patients. Controlling a patient’s symptoms allows hospice patients to experience a better quality of life with the added benefits of decreasing emergency room visits and avoiding hospital stays. Now that hospitals face penalties for readmission of patients with certain chronic conditions, Hospice of Dayton’s Focused Care program not only benefits the patients from a quality of life standpoint, but also the hospitals with readmission avoidance.

Focused Care is a specialized program of treatment that is tailored to address disease specific issues of hospice eligible patients with cancer, cardiac or pulmonary diseases. The Focused Care model uses concepts such as critical thinking algorithms, assessment guidelines, contingency orders, along with promoting collaboration between the community and hospice medical teams. After putting all the above processes in place, we recognized that we needed a way to monitor those cardiac and pulmonary patients in our program that were deemed to be the most fragile. Thus the next step was to add a tele-monitoring component to Focused Care.

Hospice of Dayton is currently the only hospice program in the area that uses tele-monitoring in the care plan for their patients. We have 20 of these user friendly devices that prompt the patients daily to complete their vital signs along with answering a set of disease specific questions. The data is transmitted each day for review by the two Focused Care Nurses during the week and triage nurses on the weekends. Admittedly, the word “micro-management” can have a negative connotation, but not in the case of monitoring our Focused Care patients! If a patient’s report shows adverse vital signs or increased disease specific complaints, the Focused Care Nurse will phone the patient real-time to further assess their needs. If necessary, patients can be instructed to use PRN medication as outlined in their contingency orders or an on-call nurse visit can be arranged for further assessment. These trends can then be reported to the hospice and attending physicians to further guide the plan of care.

Daily monitoring also provides a connection to the patient, addressing the potential isolation or anxiety that patients can experience with end-stage CHF and/or COPD. Patients learn to trust that if they have adverse signs or symptoms, they won’t be directed to go to the hospital, but can stay in their home setting and have their issues addressed quickly and efficiently. The total Focused Care approach serves to further highlight how the hospice approach to symptom management for terminally ill patients can provide positive outcomes and prevent unnecessary hospital readmissions.

Do you currently use tele-monitoring in your practice? What has your organization found to be effective in symptom management for those patients suffering from chronic conditions in the outpatient setting? Has your organization made any adaptations when providing care those patients with end-stage cardiac or pulmonary diseases?

Further information on the Hospice of Dayton Focused Care Program can be obtained at:

Self Care Activities in Summa’s Palliative Care and Hospice Services

By Rod Myerscough, PhD

We have developed a number of initiatives that we believe are creating the conditions that support good self-care. Fundamental to these efforts is the clarification of our core values so that, in the words of Parker Palmer, our “soul and role” are congruent. That is, when we know our personal, core values and our jobs conform to them, we believe that we will be effective and able to sustain a long and satisfying career.

For example, we have offered a two year training course in “The Sacred Art of Living and Dying”. This training involved four two-day retreats over two years accompanied by monthly meetings in small, four-to-six person study support groups to advance the work and learning identified in the retreats. It was designed to help the participants clarify their core values, become attentive to patients’ interpersonal and spiritual needs at the end of life, and to integrate these into their actual day to day work.

We also provided several courses of mindfulness training, a modified version of the popular eight week program, Mindfulness Based Stress Reduction (MBSR) described in Jon Kabat-Zinn’s book, Full Catastrophe Living. In it we placed special emphasis on meditation training and MBSR’s Seven Foundational Attitudes of Mindfulness (Non-Judging, Patience, Beginners Mind, Trust, Non-Striving, Acceptance, and Letting Go). We believe that when we practice these attitudes it is highly unlikely (if not outright impossible) for compassion fatigue to develop. The practice of mindfulness is uniquely situated to advance and support the goal of congruent “soul and role”.

We have also utilized poetry to advance the goals of self-care. W.H. Auden observed that “What the poet says has never been said before, but, once he has said it, his readers recognize its validity for themselves.” We partnered with Kent State University’s Wick Poetry Center to have poetry workshops in which members of the Palliative Care Team discuss a selected poem and then write one of their own. These discussions and the poetry that has emerged have been remarkably powerful experiences for the way they move the practitioners away from their usual clinical way of observing the world to one more informed by the heart’s vision. Additionally, a poem is read at the start or the end of team meetings. The poems selected are chosen because of their capacity to stimulate reflection and to help the team members see the world and themselves in a way that they would not otherwise do and, in Auden’s words, “…recognize its validity for themselves.”

The intention behind all of these efforts is the maintenance and, if necessary, the restoration of the practitioner’s sense of competency and wholeness. Our self-care strategy assumes that we already have all that we need, although it is certainly possible to forget this and to become lost and burned out. Our hope is that these and other initiatives will prevent compassion fatigue, promote good patient care, and allow practitioners to have long-lasting and meaningful careers in Palliative Care.

For more on Summa’s Palliative Care and Hospice Services, visit AAHPM’s Profiles in Innovation.

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.

Bridging the Gap in Advanced Illness

Michael Paletta, MD FAAHPM

Many of us practicing hospice and palliative medicine have long struggled with the gap between persons coping with advancing illness and persons failing despite aggressive management. Patients seem to cross from the first group to the second quickly, almost without notice. Late referral to hospice is a natural result of this difficulty in identifying patients who are properly managed and compliant, yet whose disease is progressing, and whose final months often feature crisis care in emergency and intensive care settings. Palliative care offers interdisciplinary management, but trained providers are few, and services in many areas remain tied to hospitals and medical centers.

We at Hospice of Michigan, through our innovation division − The Maggie Allesee Center, sought to identify persons with serious illness earlier in their decline trajectory, before the suffering and the cost of multiple hospitalizations devastates their final months. Using Medicare claims data and a proprietary predictive model, we developed an integrative program, At Home SUPPORT ™, blending EMR access, telephone support, after hours visits, and family/caregiver training. The caregiver emphasis has been particularly effective for, after all, it is they who call 911 in a lonely panic, or encourage hospital admission as respite for their own exhaustion. Our partnerships with Accountable Care Organizations focus on the 5% of patients who generate 50% of costs and have yielded data supporting diminished ED use, fewer hospitalizations, increased and earlier referral to hospice, and diminished caregiver burden. As we expand our partnership database, we plan to further refine this model to a replicable program of advanced illness management.

Has your institution considered ways to reach patients and families earlier in the trajectory of serious illness? What can we learn from one another as we travel this road?

Dr. Paletta serves as Vice President of Medical Affairs for Hospice of Michigan. This post previews the latest installment of AAHPM’s Hospice and Palliative Medicine Profiles in Innovation.

How to Start an Outpatient Palliative Care Program

Sharon Tapper, MD

About 5 years ago, it became clear to me that patients seen by our Palliative Care Service in the acute hospital (1) needed follow-up when they were discharged, (2) many would not have wanted to be there in the first place, and (3) most did not have their wishes documented in an actionable format prior to admission.

I am part of a multi-specialty physician group without a Palliative Care Department. So, how do you start a program from “scratch”? What I did was visualize the utopia I wanted to create… a system of care delivery that puts the patient/person/family at the center of care and a mobile multidisciplinary team follows that patient in the last year of life — regardless of the physical location of the patient. This includes visits to home, nursing home, LTAC, office, hospital, etc. The pillars of care are symptom management, advance care planning, including attention to documentation of goals of care and POLST.

To start, I created a PowerPoint presentation with my “ask.” This included a definition of palliative care, slides with studies demonstrating the proven benefits known in the hospital/outpatient setting of cost savings, symptom management, etc. I also created an “old paradigm” (i.e., the current patient experience) and the “new paradigm” — how that patient’s experience would change with the creation of the new service. I did a cursory calculation of financial needs based on how much the physician/NP would bring in with work RVUs and how much the program would cost to run. It was mostly labor overhead as we utilized clinic space already built. This helped to define the financial contribution needed to fund the program.

I got leadership buy-in for the program with the PowerPoint. This is one of the keys to success. The other is getting physician buy-in. They are your referral source. I did this by having physicians involved with the planning of the program. Once the program was in the pilot phase, I developed another presentation specifically directed to the physicians. I went to all primary care and select specialty meetings to describe the program, how to refer, etc. This was before the first patient was enrolled. Other stakeholders are the local hospices, home health agencies, hospitals and nursing homes.

Well, we have been up and running for 2 years. We have seen over 1,000 patient/persons/families and will have completed the rollout to our 900,000 patient base by the first quarter of 2014.

Have you started a new program at your institution? How did you generate support for the idea? Were there pitfalls you didn’t expect? I hope that sharing the lessons we’ve learned along the way will help guide our colleagues starting out on this road and lead to better care for more patients.

Dr. Tapper serves as Medical Director of the Palo Alto Medical Foundation’s Outpatient Palliative Care and Support Services. This post previews the latest installment of AAHPM’s Hospice and Palliative Medicine Profiles in Innovation.