Archive for December, 2010

At the White House: ACA Implementation—An Opportunity to Advance Palliative Care

During my year as AAHPM President, I’ve had many opportunities to represent the Academy and have often been on Capitol Hill, looking to expand access to palliative care through the public policy process. On Dec. 17, the Obama administration held a meeting with community physicians at the White House to seek input about implementation of the Patient Protection and Affordable Care Act — the healthcare reform law. I was honored to be invited to attend and represent AAHPM members, as well as the other member organizations of the Hospice and Palliative Care Coalition (NHPCO, HPNA, CAPC, NPCRC and NASW).

This meeting—the first in a series—was hosted by Zeke Emanuel, MD, special adviser for health policy in the Office of Management and Budget (and brother of Obama’s former Chief of Staff Rahm) and the new CMS administrator, Don Berwick, MD, who provided a brief update on delivery system reform. The primary focus of the event, however, was to hold an open dialogue, so all participants were invited to come prepared with any questions or concerns they would like to raise. Much of the discussion focused on the launch of a new patient safety initiative and proposed rules for accountable care organizations (ACOs) participating in the Medicare program under the Affordable Care Act. I went on record stating the importance of palliative care in terms of improving quality of clinical care, improving family experience, and reducing cost. I urged inclusion of palliative care in the new ACO’s. (Read the Academy’s official comments to CMS regarding ACOs.)

There are many parts to the healthcare reform legislation, but many of the specifics are left to be defined through the rulemaking process. It will be important to see where the Academy can have the most impact by weighing in on these efforts. Last month, AAHPM joined with its Coalition partners in providing comments to the Institute of Medicine as it studies the Essential Health Benefits outlined in the Affordable Care Act. The Coalition urged officials to ensure that palliative care and hospice care are defined as essential components of all insurance plans offered under the government’s exchange, in order to deliver quality care for the nation’s sickest and most vulnerable patients. I’ll have a chance in January to speak to the IOM Committee working to define these benefits.

While I am pleased to be the voice of AAHPM’s membership, mine is not the only voice that officials want to hear. We’ve come to learn that they are looking to see not only which folks but how many folks are weighing in on these issues as a guide to how significant an issue may be. When there are opportunities for public comment that AAHPM has identified as an avenue to advance palliative care and hospice, we’ll include the details in e-News. I encourage you to follow up on these alerts. And don’t forget that you can always weigh in on legislative matters as well, directly contacting your representatives in Congress using AAHPM’s Legislative Action Center.

Innovations in quality improvement: help spread the word!

JPSM has announced a new call for brief reports explaining the results of quality improvement initiatives in palliative care. JPSM associate editor David Casarett and members of the AAHPM Quality Task Force were puzzled by the dearth of good information about what quality improvement innovations programs are finding successful. They realized that there aren’t many good venues for sharing the results of quality improvement initiatives, since the journals typically focus on publication of more traditional research. Thus, the idea was born for a special JPSM series on quality improvement, which will review submissions against criteria appropriate to quality improvement, not research. This series is aimed at sharing quality improvement initiatives in hospice and palliative care so that we begin to build a shared body of knowledge about what works (or doesn’t) to improve hospice and palliative care.

If your program has a quality improvement innovation of which you are proud, please take the next step and share it with your colleagues via the JPSM series. Submissions are due April 15, 2011. More information about the call.

The Evolving Role of Hospice and Palliative Medicine Leadership

As hospices and palliative care services evolve into advanced palliative care organizations with greater scope and influence over late-life care within their communities, a “new” physician executive role is emerging along the career path for HPM physicians. This role is broader than the traditional senior medical director or chief medical officer positions, and is progressing toward what we refer to as the “chief community palliative care officer”.

These physician executive positions have proven to be instrumental in shaping late-life care practices by applying management competencies to:

-build and sustain relationships that evolve into community-wide palliative care networks

-disseminate throughout a community the use of metrics and evidence-based practices to hold practitioners to high standards of performance

-inspire referring physicians and HPM medical staff members to meet clinical outcomes and family satisfaction metrics

-envision and stimulate a change process that coalesces the community around new models of late-life care

Daunting challenges, to be sure. As hospice executives and HPM physicians come to grips with impending rules around face-to-face recertification requirements, and other day-to-day operational issues, we would all do well to remain mindful of the strategic leadership objectives that will ultimately determine how successful we are in transforming late-life care in the US. We’ve seen the importance of the role of HPM leadership in exemplar communities across America. To “spread the science ” of HPM is our next challenge.

HPNA/AAHPM Collaboration for Annual Assembly

For the past 6 years, AAHPM and HPNA have collaborated to provide an annual conference for members of the interdisciplinary team. As we would expect, the outcomes have improved annually. Last year’s conference in Boston, recorded the highest attendance, the most satisfied attendees and highest rating for presenters.

Is it possible to improve? With any process, there are always opportunities to improve. This year’s conference committee co-chairs and more than 60 volunteer committee members have been committed to raise the bar even higher. HPNA will be kicking off a year-long celebration of their 25th Anniversary with many specialty events so we encourage you to come see, enjoy, network and grow professionally. While there, ask about the Hospice and Palliative Nurses Foundation walk-a-thon. It is a great way to exercise and support grants, scholarships and awards in research and education. See you in Vancouver, B.C. – remember your passport!!

“What the heck is CMSS and why should I care?”

You may be asking yourself, “What the heck is CMSS and why should I care?” While I knew that this stands for Council of Medical Specialty Societies, I attended their recent annual meeting with less than a full appreciation of what this is and why it matters to us doing Hospice and Palliative Medicine. Afterwards, I have a much better understanding. Sitting through various presentations that included slides predicting not just political ‘fireworks’ in the coming year, but political ‘nuclear explosions.’

So what is CMSS? It is a place where the specialty societies that have ABMS primary Boards and an increasing number of subspecialty societies, like AAHPM, can come together and interface with each other, and with a number of other associated entities, like the Federation of State Medical Boards, the Association of American Medical Colleges, the National Board of Medical Examiners, the Accreditation Council for Continuing Medical Education, and others. The entities just named all provided speakers who educated the attendees on what is happening within their bailiwicks, as it relates to what we, the practicing physicians do.

Besides the aforementioned mention of how the November elections have obliterated many predictions of what to expect legislatively over the coming year, in depth discussion of the following was provided. CMSS, itself, has sponsored and promulgated the CMSS Code for Interactions with Companies, (what is known as ‘the Code’), providing guidance for how member societies can craft their members’ and leaders’ relations with industry, especially in light on the likelihood of passage of the “Sunshine Act,” which will require reporting of industry payments to physicians. AAHPM has already signed onto the Code, which is available online at

Physician workforce shortages were addressed by various entities, including AAMC, with discussions centering around deficiencies in how we select physicians, with current selection tools only accurately predicting how well students will do in the first half of medical school, rather than how well the future selectee will meet expected demands as practicing physicians. FSMB and ACCME discussed Maintenance of Licensure and Maintenance of Certification, and what to expect in the coming decade. ACGME duties hour limitations for residents were also discussed.

As the newest member of this august organization, AAHPM’s representatives were welcomed with open arms by the other member representatives, giving further indication that HPM is increasingly recognized as a crucial component of the entire continuum of medical practice. It was my privilege to represent the Academy, following up on the groundwork laid by Gail Cooney, our immediate past president. Other Academy representation included Steve Smith, our CEO, Laura Davis, director of marketing and membership, and Julie Bruno, director of education and training.

AAHPM’s First RFS Representative’s Perspective on AMA Interim Meeting

My name is Devon Fletcher. I’m a Hospice and Palliative Medicine Fellow at the Virginia Commonwealth University Health Systems in Richmond, VA.

I recently had the opportunity to attend the American Medical Association’s Interim Meeting in San Diego this November as the AMA’s first ever AAHPM representative to the Resident and Fellow Section (RFS).

I’d been fairly active in the Medical Student Section (MSS) of the AMA during medical school but after moving to a new place and trying to focus on residency it ended up being years since my last AMA meeting. When I heard about this opportunity to rejoin the AMA I jumped at the opportunity to be more involved in organized medicine again.

Going to these meetings can be a little daunting the first few times. Things move fast. There are a lot of acronyms and abbreviations that get thrown around about which I had to refresh my memory! There has to be a “game plan” going in. It’s like a bee hive: People coming and going, everyone on their own little mission for the good of the whole. As part of the RFS, as in the MSS, I was again impressed with the number of articulate, dedicated hard working young residents and fellows working to improve health care delivery for our patients and for the working conditions affecting physicians.

Elected delegates from the MSS and RFS bring forward opinions from these sections to the House of Delegates Meeting (HOD) a few days later. Even with my previous experience with the AMA, I was reminded at how vast the medical community is across the nation. Being able to participate in a national debate with opinions from a wide variety of physicians and providers from around the country is incredibly eye-opening experience. It is important to understanding the common issues we face as physicians and discussion concerning how we can face these problems as a group.

Of course there were plenty of educational opportunities including a session on advance care planning —which just so happened to be led by one of the doctors from my medical school training in Jackson, MS.

The RFS is split into “regions”. Regions 1-7 are basically geographic sections. Region 8 is the subspecialty section with representatives from many of the major medical subspecialty societies across the nation. Our specialty section would like to have a conference call/tele-meeting to just discuss the issues going on with each field … really just for our own education. If any AAHPM members have anything they want other fields to hear or know about hospice and palliative medicine or there are major topics you would like to bring up that affect our field, get in touch!

If you want to get involved for the upcoming meetings you could also apply for an At-large delegate position!

More on the AMA-RFS 2010 Interim Meeting.

Happy 100th Anniversary, PC-FACS

The 100th issue of PC-FACS, an AAHPM signature service, represents a milestone. Celebrating this century issue, Editor-in-Chief Amy Abernethy commented on trends in palliative care since the digest’s inception. Read the 100th issue of PC-FACS.

(1) Increasing acceptance of palliative care as a discipline. The palliative care philosophy now extends into diverse settings including mainstream medicine. Once identified with end-of-life care, palliative care now defines care delivered appropriately throughout complex life-threatening illnesses.

(2) Systematic development of an evidence base, and iterative refinement of a toolbox, for palliative care practice. Research now includes rigorous randomized controlled trials and systematic reviews as well as observational studies, and addresses a wide spectrum of clinical issues and outcomes ranging from quality of life to health service utilization.

(3) Basic science exploration. Complementing clinical studies, basic science can provide insights into, and a biological underpinning for, clinical observations. Bidirectional conversation between basic scientists and clinicians will help develop, evaluate, and refine the next generation of interventions, and continuously improve quality and outcomes.

(4) Examination of quality. Efforts to define quality will allow us to benchmark clinical practice, advance/improve standards, identify effective approaches, and disseminate best practices.

Concurrent Palliative Care-Peace of Mind in the Setting of an Uncertain Prognosis; Part 1

This post is Part 1 of a multi-part series.

Concurrent Palliative Care – Peace of mind in the setting of an uncertain prognosis

Jean S. Kutner, MD, MSPH

I was in Asheville, N.C. for a professional meeting when I received a call from a medicine resident at our hospital saying that she was transferring my mom to the ICU for closer management of her intractable dyspnea (shortness of breath). My mom, who has an atypical presentation of Parkinson’s, had been admitted to the hospital with tachypnea (rapid breathing) and respiratory alkalosis (low blood pH caused by rapid breathing) ~ 5 days earlier. While she had been having odd episodes of shortness of breath for several months prior to this hospitalization, her Parkinson’s had been relatively mild, with no episodes of aspiration and good functional status. She had seemed to be improving when I left town and I had fully expected that she would be discharged by the time I returned home. Things clearly had changed for the worse. Speaking with my dad did little to relieve my growing anxiety – he told me that she had developed tachypnea and respiratory alkalosis again, had exceeded the monitoring capacity of the regular medicine unit, and was being transferred to the ICU to facilitate higher benzodiazepine dosing to attempt to control what was eventually diagnosed as a respiratory dyskinesia, thought to be a rare side effect of the carbidopa/levodopa she was taking to treat her Parkinson’s symptoms.

While I had complete trust in my medicine, pulmonary and neurology colleagues who were attentively caring for my mom and monitoring the situation, I felt helpless without having eyes and ears ‘on the ground’. It didn’t take me long to reach out to my palliative care colleagues for help. Who better to quickly assess and inform me about a situation involving an apparently deteriorating clinical situation and prognostic uncertainty? I sent a text message to our palliative care advanced practice nurse – “my mom’s being admitted to the ICU, I’m out of town, can you find out what’s going on?” Reaffirming the wonderfully supportive colleagues we have in this field, she and the rest of the palliative care team quickly went to the ICU to check on my mom – and to see how my dad was doing. Their call to me was at the same time chilling and reassuring – “she looks really uncomfortable – we told the ICU team that we recommend intubation for her comfort”. I’ll bet that is one of the few times that the ICU team has heard palliative care recommend intubation. New mantra – if the palliative care team recommends intubation, the patient probably really needs it.

I stayed in close contact with the palliative care team over the next day as events evolved and I was able to work my way back to Denver from Asheville. It gave me great peace of mind to know that I had trusted eyes and ears present who were looking out for both my mom’s comfort and my dad’s well-being.