Hospice and Palliative Medicine
by Katie Macaluso, AAHPM Associate Editor
We asked AAHPM members last fall why they read the Academy’s member newsletter and what they might like to see included. The result of that survey and ensuing editorial board discussions is the newly redesigned AAHPM Quarterly (formerly the AAHPM Bulletin); if you are a member, it should have landed in your mailbox during the past few weeks. The spring issue showcases a design that matches the current branding of the Academy and includes a variety of articles related to hospice and palliative care practice.
Interested in what the field of palliative care looks like in other countries such as Vietnam, Uganda, and Nepal? Read Marcin Chwistek’s article on page 12. The Art of Caring column on page 18 shares strategies for coping with the burdens of the profession through creative writing. AAHPM’s recent advocacy efforts and ways you can become involved with policy are discussed in the Advocacy Update on page 6, and Bruce Chamberlain, Gail Cooney, and Chris Acevedo unravel the specifics of face-to-face encounters on page 11. Finally, read about AAHPM President Ron Crossno and his encounter with the “presidential seal” on page 16.
Read the full issue here. (Along with the redesign, we’ve gone to a digital vender to make each issue more interactive and functional.) What do you think about the new look? What more would you like to see in the Quarterly? I know I can speak for the rest of the AAHPM Quarterly Editorial Board in saying that your opinion is highly valued and much appreciated as we continue to refine content in the newsletter.
by Jen Fuhrman-Kestler, AAHPM e-Marketing Manager
“FYI…we’re getting hitched tomorrow.”
This was the text I received from my fiancé as I sat in the opening session of a membership and marketing conference. Although he made me chuckle with his deliberate flippant wording, I quickly understood the significance of what was about to happen within the next 24 hours.
My now mother-in-law, Barb, has been in poor health for the past few years, and has gone through a myriad of medical treatments for her many different serious illnesses. After a stay in the ICU, she decided to move to hospice.
Being an employee of AAHPM, and advocate of palliative care, I was pleased with her decision to focus on quality of life and relieved that her uncomfortable symptoms would be managed.
The team at Shell Point Hospice has helped align a care plan with my mother-in-law’s goals. She is a strong and independent woman, never afraid to voice her opinion. Her first request was a view of the water. Her room on the fourth floor overlooks a lagoon filled with manatees, dolphins and tarpon. After being in the ICU and limited to a few spoonfuls of ice chips, nothing sounded better to her than a strawberry milkshake. Removing all the limitations and restrictions and allowing her to enjoy her remaining days has made Barb very happy, but the greatest gift Shell Point was able to give her was perhaps the most unconventional.
When Barb’s prognosis meant that she would not be able to make our late July wedding, Shawn and I decided to bring the wedding to her. After my conference, I got the first flight to Fort Myers. The next morning, we stopped by the Publix to pick up some flowers and a small cake. When the woman at the bakery asked if the cake was for a special occasion, and we answered “our wedding,” she looked as if she didn’t believe us. We arrived at the hospice and spoke with the chaplain, Dewey. He quickly got to know Shawn and me, and within a half an hour, we had a ceremony. Michelle, the social worker, took photos, and three of Barb’s closest friends joined her to witness our promise to spend the rest of our lives making one another happy.
We are so grateful that we could share our wedding with Barb, and so appreciative of the work done by the hospice team to accommodate our rather unusual request. It was a tear-filled day, but each one shed was the result of love. Barb was beaming and counted it as one of the single-greatest joys of her life. Shawn and I were beaming too.
Steven (Skip) Radwany, MD, FACP, FAAHPM, is the Medical Director of Summa Health System’s Palliative Care and Hospice Services, and Professor of Medicine, Northeastern Ohio Universities Colleges of Medicine and Pharmacy. Dr. Radwany is the AAHPM Ethics, Advocacy and External Awareness Strategic Coordinating Committee Chair.
This comes in follow-up to my post a couple of months ago regarding our relationships within organized medicine and academic medicine via the Academy. I recently attended the American College of Physicians (ACP) Annual Meeting in San Diego, California, from April 5-10, 2011. I was able to obtain some of those valuable Maintenance of Certification Points during a pre-course in order to finalize preparations for my Geriatrics re-certification.
As always, this ACP sponsored meeting offered hundreds of excellent presentation from which to choose. The schedule exhibited great depth and breadth in with one significant exception:
Out of the hundreds of subspecialty and generalists offerings, including a complete track for hospital medicine, there were only 2 explicit Hospice and Palliative Medicine offerings on the schedule. These were provided by Jean Kutner, AHHPM Board Member and Keith Swetz, AAHPM Member.
Under listing of topical areas on the schedule included all of usual suspects: Cardiology, Dermatology, Endocrine, Geriatric Medicine, Gastroenterology, etc., yet Hospice and Palliative Medicine did not appear to be recognized as a distinctive or important specialty.
Nonetheless, the largest proportion of certified Hospice and Palliative Medicine specialists are internists. Additionally, the largest proportion of Hospice and Palliative Medicine Fellowship Programs are housed in or attached to Internal Medicine Programs. Thus Internal Medicine and Hospice and Palliative Medicine are clearly joined at the hip. Yet the relative absence both in name and person from Internal Medicine’s largest annual meeting suggests a bit of a disconnect.
We must collaborate extensively with Internal Medicine generalists and subspecialists in order to provide the highest quality care to our patients. We certainly need to be fully recognized and able to stand tall amongst our fellow Internal Medicine subspecialties. Some of the disconnect could reflect the integrative character of out specialty, yet General Internal Medicine, Geriatric Medicine, and Hospital Medicine all have prominent roles in this annual meeting.
Another barrier or concern might be the large number of sponsoring general specialties from which one can enter the field of Hospice and Palliative Medicine including Radiology, Pediatrics, Neurology, etc. This broad “ownership” of Hospice and Palliative Medicine may dilute the attention of organized Internal Medicine to our field though dual sponsorship of Geriatrics by Family Medicine and Internal Medicine has had no such effect.
So, where do we go from here? The concern I express above comes attached to the concern I expressed previously about HPM’s lack of recognition within the Alliance for Academic Internal Medicine. We must be visible and proactive, and we must communicate with our own Academy about existing or potential external relationships or roles we might have in other areas of organized medicine. Also, we should accept any invitations to speak at meetings such as the ACP’s and participate in leadership roles whenever possible. Sometimes to get a seat at the table you need to bring your own chair and politely elbow your way in.
And for those ACP members out there, the site below would allow you to submit a clinical skills workshop for the 2012 meeting or a presentation for the 2013 meeting:
I attended the NHPCO Conference and this year it was different. I’m a committed member of the tweeting subculture inspired by my twitter buddies after reading live commentary from sessions at the recent AAHPM conference in Canada.
I had not planned it before going to the conference but fell into it as I listened to the first session. My initial thoughts…..take notes in the form of tweets that I can review later. But with time and the growing joy in it, I embraced the mission to benefit to the bigger audience and resolved to tweet notes that others could follow, giving credit to the presenters & bringing the message to more people. I felt like a reporter bringing tales from the edge. I reveled at bringing the results of the Moran report to the twitter community, giving insight into the issues affecting the multigenerational hospice workforce, CMS’s recommendations about the Face to Face Visit regulations or bringing eAdvocacy strategies. It changed my conference experience completely. People around me asked what I was doing punching madly on my blackberry and became starry eyed at the thought of stardom in Twitterwood!
A highlight was meeting fellow tweeters. No introductions needed, we already know each other on a different level. I laugh as I approached them in hallways and at the bookstore “Hi!—– EOLnavigator. Great to finally meet you IRL (in real life). My real name —–Niamh!”
So what’s the point of tweeting live from a conference? Our collective mission is to get everybody passionate about end of life care with something to say about it online bringing their expertise to the masses and bringing the conference experience to non-attendees. I won’t miss another AAHPM conference & you can expect tweets on the road, not literally speaking! Read our tweets for the conference at www.tweetchat.com and enter #mlc11 hashtag or follow the #hpm hashtag to meet your online hospice and palliative care brothers and sisters.
The Journal of Pain and Symptom Management is pleased to announce a call for papers that report the results of Quality Improvement initiatives in palliative care.
This publication of brief reports is a joint project of the American Academy of Hospice and Palliative Medicine and the National Hospice and Palliative Care Organization. Papers focusing on hospice and palliative care settings are encouraged.
The Journal offers this professional forum to encourage dialogue, peer review, and dissemination in response to a growing international concern about quality care, patient safety, and the role of evidence-based medicine. Submissions should describe specific Quality Improvement projects, such as efforts to increase pain screening, encourage goals discussions, promote palliative care consults, encourage earlier hospice referrals, or support staff well-being. Submissions must describe the impact of the intervention, either in terms of change over time or relative to a comparator.
Papers will be considered Brief Reports and must include the following:
1) A structured abstract of <150 words with five headings: Background, Measures, Intervention, Outcomes, Conclusions/Lessons Learned.
2) Five sections—Background, Measures, Intervention, Outcomes, Conclusions/Lessons learned—requiring no more than 1,250 words
3) No more than 10 references and two graphs or tables. (References/tables/ graphs are not included in the word count.)
4) A cover letter specifying that the Brief Report is being submitted in response to this Call for Papers.
Papers that fulfill the length and formatting requirements will undergo preliminary review by the Editors, and some will undergo external peer review. Acceptance for publication will depend on evaluation of the problem addressed, innovation, quality of the description, and clinical relevance of the intervention and outcomes.
Manuscripts submitted in response to this announcement should be submitted online to the Journal of Pain and Symptom Management (http://ees.elsevier.com/jps/) by April 15, 2011.
For questions regarding format or content of potential manuscripts, please contact Dr. David Casarett (Casarett@mail.med.upenn.edu).
Last week, President Obama declared April 10-16 National Volunteer Appreciation Week (April 10-16, 2011). In the proclamation, he states:
America’s story has been marked by the service of volunteers. Generations of selfless individuals from all walks of life have served each other and our Nation, each person dedicated to making tomorrow better than today. They exemplify the quintessential American idea that we can change things, make things better, and solve problems when we work together.
On behalf of the American Academy of Hospice and Palliative Medicine (AAHPM), I would like to thank all of our members who share their time and talent with our Academy – and those that volunteer time to assist our members in the care of patients, families and communities.
Thank you for all that you do!
Steve Smith, CAE
Executive Director & CEO
American Academy of Hospice and Palliative Medicine
I have always yearned for a Medicare Benefit for palliative care services, so it was with some excitement that I read an e-mail from MedPAC inviting me to a meeting in Washington March 23, to discuss palliative care.
The Medicare Payment Advisory Commission (MedPAC) is an independent Congressional agency established by the Balanced Budget Act of 1997 to advise the U.S. Congress on issues affecting the Medicare program. The Commission’s statutory mandate is quite broad: In addition to advising the Congress on payments to private health plans participating in Medicare and providers in Medicare’s traditional fee-for-service program, MedPAC is also tasked with analyzing access to care, quality of care, and other issues affecting Medicare.
The Commission staff invited a diverse group of palliative care specialists to come to Washington to discuss general issues such as the definitions and scope of non-hospice palliative care, the strength of the evidence that palliative care improves quality, outcomes, and service use, and factors that enable or hinder the delivery of palliative care.
The conference was attended by MedPAC staff, a moderator from the Lewin Group, and Janet Bull (Four Seasons, NC), Lyn Ceronsky(Fairview Services, Minneapolis), Timothy Keay (U Md Ca Center, Baltimore), Randall Krakauer (Aetna, NJ), James Lee (Everett Clinic, Washington), Diane Meier (CAPC , NY), Susan Mitchell (Harvard Aging Research, Boston), Michael Nisco (UC & Hospice, Fresno), Russell Portenoy (Beth Israel, NY), Greg Sachs (U of Indiana Aging Research, Indianapolis), Linda Todd (Hospice and PACE of Siouxland, Indiana), and myself.
It soon became clear that a new benefit for palliative care services is not on anyone’s drawing board, but the inclusion of palliative care services in new initiatives like Accountable Care Organizations, Community Health Teams to Support the Patient-Centered Medical Home, Hospital Value Based Purchasing, or Center for Medicare and Medicaid Innovation at the Center for Medicare Services is a possibility.
It was an energized discussion of wide-ranging aspects of our field, and we all hope the MedPAC staff can use what they learned from us to help Medicare beneficiaries with serious illnesses get the best possible care.
Porter Storey MD
Executive VP, AAHPM
Colorado Permanente Medical Group
A Palliative Care Summit was recently convened in Philadelphia by the School of Population Health at Thomas Jefferson University. It was described as the “First National” and the “Leading Forum on Palliative and End-of-Life Care”.
An impressive array of speakers over the two days. Diane Meier,MD, Sean Morrison, MD, Don Schumacher, David Wennberg, MD, Christine Richie, MD, Terri Maxwell, PhD,APRN, James Cleary, MD.,Todd Hultman,PhD,APRN to name but a few. A roster of thought leaders in the field. Compelling cases were made during the presentations on why hospice and palliative care (is/are?) the solution to many of the health care industry’s woes.
Meanwhile, just next door, other industry thought leaders were offering compelling cases on why “medical homes” or ‘expanded chronic care models” or “mobile technology” were desirable solutions for transformation of the health care system.
In other words, competing, or one might say, conflicting visions. These competing/conflicting visions exist across specialties, and within them.
Dr. Morrison addressed this issue when he stated that the public and professionals are confused by references to hospice and palliative care , as if these were two distinct fields or sectors.
While my training is as a health executive, I’ve spent much of my professional career advancing the work of palliative care/hospice professionals and organizations. So I pay closer attention to the hospice/palliative care field, and how it may best fit into the larger health care system. And as Dr. Morrison stated directly, and others commented more indirectly, while progress has been made over the past 15 years, the institutional culture of dying in the US has not dramatically changed. I refer to palliative care as one parts accomplishment for every three parts of potential. Yes, we have a long way to go, indeed.
At the end of the Summit, I was left with a nagging question: If hospice and palliative care are such an obvious solution, then why hasn’t the “art” and “science” of hospice and palliative care spread more quickly and widely than it has? No simple answers to be sure. Yes, many of the speakers offered calls (some powerful) to action. Yet calls for action have been sounded for the past 15 years, with some, but most would argue, insufficient progress. Why? The promise of palliative care to improve late-life care has been stymied by a highly fragmented field of hospice and palliative care where stakeholders are perpetually “staking”out their ground.
Some suggestions for the Second National Palliative Care Summit. Let’s have discussions around:
*How nursing AND medicine can best collaborate to improve access to palliative care in all settings across the community.
*What NEW organizational models might best bring together key stakeholders in late-life care within a community?
*What can be learned from communities whose late-life care practices make them exemplars?
Finally, we need a unifying campaign to improve late-life care in the US. Here’s a suggestion. The 30/30/30 Campaign. A national campaign carried out locally/regionally.
Something like the following:
*No more than 30% of deaths occur in hospitals.
*At least 30% of deaths in hospital are consulted by palliative care specialists.
*No more than 30% of patients who die will be enrolled in hospice for 10 days or less.
Your comments, ideas, feedback are, as usual, invited.
This past fall my husband had several hospitalizations, culminating with the planned re-admission for surgery which we thought would pretty much clear up his recent problems. The day of surgery, we had no clue that his surgery would take over 7 hours, and end in him being placed in the ICU. But even then, I was positive that it was just overnight after a prolonged anesthetic. It wasn’t, it was the start of a two week nightmare that found me floundering. While I work a a very large Academic Medical center, Palliative Medicine is still in its infancy. So our Service consists of me and my NP( and of course SW and Pastoral Care). At the end of the first week, knowing my husband’s feeling about life prolonging care, I began to get concerned about who would I look to, if I needed advocacy as the patient’s wife? I called Pal Med Connect. I don’t recall the name of the doctor who spoke to me, listened to me cry, and provided both solace and suggestions, but she was great! And she called back several days later, too. I was able to think more clearly and make some plans. I even was able to suck up the courage to take my boards . Yes, he was still on the vent on Nov 16th, when the exam were administered, and my brain was Swiss cheese, but the testing center was only 2 miles from the hospital and my sons stayed with him, while, I played with the computer.
My husband survived, and 3 months later, he is till not well, but slowly improving, by the grace of God. And another Grace? I passed the CAQ! Who knew that taking boards when you’ve had no sleep, not eaten and are maximally stressed could be so efficacious for scores!
We [the CMS] believe the role of the physician within hospices has been undervalued, and we would like to see the physician’s participation increase in the care of long-stay patients. That’s one of the messages to take away from the CMS regulation mandating physician (or nurse practitioner) face-to-face encounters to certify a patient’s continued hospice eligibility. The Medicare program reimburses a hospice nearly $30,000 over a six-month period to provide for the total healthcare needs of a patient with advanced illness- a single physician visit to that patient’s residence over that period isn’t too much to require, is it?
To me, it seems likely that such patients would benefit from a care planning visit by a physician. After all, the distinguishing feature of hospice care from most other care covered by Medicare is its collaborative nature, and the primacy of the interdisciplinary team.
Such care, of course, lies at the core of palliative medicine.
Rather than treating this regulation as a compliance issue, hospice executives, and physicians, would do well to incorporate physician recertification visits into their clinical practice patterns. One can be confident that patients, and their families, will appreciate the value of these visits.
Recently, a family member passed away after a broken hip confined her to a skilled nursing facility. A hospice program served her during her final three months. During that time, she was not seen by a hospice and palliative medicine physician. And while her (and the family’s) hospice experience was positive, the interdisciplinary team concept seemed incomplete without a single bedside appearance from the physician.