Archive for January, 2011

Entrenching Hospice and Palliative Medicine in the Firmament of Organized Medicine

Some general questions arose in my own mind during my participation in the Association of Specialty Professors Council recently. First, by way of background, the Alliance for Academic Internal Medicine (AAIM) is a consortium of five specialty organizations representing departments of internal medicine at medical schools and teaching hospitals throughout the US and Canada. One of those five is the Association of Specialty Professors (ASP) which is the organization of the internal medicine divisions at medical schools and community teaching hospitals in the US and Canada. The ASP is compromised over 1000 members with 89 medical educational institutions represented. Its focus is on fellowship education, leadership development, and research. I currently serve on the Council of the ASP as the “Community Hospital Representative” (though I informally advocate for HPM as best I can). I was nominated and appointed to this position after participating in some of AAIM and ASP’s education and development programs.

This national council meets by conference call monthly and face to face twice a year. Looking at the membership, all of the typical subspecialties of internal medicine are represented: nephrology, cardiology, rheumatology, etc. Hospital medicine is now officially recognized as a specialty on this council though Hospice and Palliative Medicine is not. This struck me as unusual given that Hospital Medicine does not have an ABMS certification process nor are there specific accredited training programs in Hospital Medicine. This is not to demean Hospital Medicine in any way as its value to patients, health systems and medical education has become abundantly clear in recent years. Nonetheless looking also to the American College of Physicians formal representation or involvement from Hospice and Palliative Medicine does not exist within that largest specialty society of internal medicine. With the greatest proportion of HPM specialist being internists this will hopefully change over time.

In general our relationships within academic and organized medicine from Hospice and Palliative Medicine have grown organically over time. We clearly have a growing relationship with the AMA and strong representation within its governing bodies. How AAHPM relates to other organizations such as ACP, ACS, AAFP, AAN and AAP is something our members and leadership will further address over time. AAHPM staff have created a grid for the External Awareness Task Force of the external relationships that already exist and the nature of those relationships. Again, our members and leadership will decide how these relationships should be prioritized over time and what the nature of these relationships should be. Should there be liaison representation on the boards of some of the large organizations? Is that an appropriate way for hospice and palliative medicine to become more entrenched in the firmament of organized medicine? What will be the most efficient and effective way for AHHPM to utilize its limited resources in developing these relationships? Where do we get the most bang for the buck so to speak? At a minimum it seems that we need to continue to identify AAHPM members who hold leadership positions or are potential candidates for leadership positions in some of the important organizations which interface with hospice and palliative medicine in both education and practice. As individual members we can greatly further this process by seeking involvement in the professional societies representing our primary specialties whenever such opportunities arise. At a minimum we can informally advocate and educate for our field from those positions especially given our accustomed roles as patient and family advocates. Over time these roles may evolve from informal to formal. Keeping AAHPM aware of any such activity should offer all of us greater opportunity to help our patients and promote our specialty.

Diving into the Alphabet Soup of PQRI

Four Seasons Hospice has taken the plunge and begun to participate in the Physician Quality Reporting Initiative (PQRI) of Medicare. Since fall 2010, we have successfully been submitting data on three PQRI measures: #47 (Advance Care Plan), #154 (Falls risk assessment), and #155 (Falls plan of care). Our palliative care program extends across the inpatient and outpatient setting and services are delivered by nine midlevel providers and four physicians. We incorporated these PQRI metrics into our database collection tool, and educated our providers on the importance of accurately documenting these metrics. It was equally important to train our administrative and billing department on proper ways to track and code these metrics. Our hope is that future measures will be specific to our field and will eventually serve the purpose of the PQRI program, which is to ultimately improve quality care to our patients. In the meantime, we are gaining experience with the program so that we will be ready when participation becomes mandatory.

We have prepared a brief guide to the PQRI process to help other hospices who are considering participating in PQRI.

We are very interested in hearing about the experience of any other hospice or palliative care program that is participating in PQRI. Please leave a comment on the blog and let us know who you are. Let’s trade experiences and support each other.

One Voice, One Message

Hospice and Palliative Care Coalition Leaders Commit to Collaboration; Aim to Speak with “One Voice”

The organizational members of the Hospice & Palliative Care Coalition met in Washington DC in December 2010 to discuss recent, current and future opportunities for collaboration including ways to develop consistent and supportive messages on behalf of the entire field of hospice and palliative care whenever possible.

The Coalition was founded in 2001 when the American Academy of Hospice and Palliative Medicine (AAHPM), the Hospice and Palliative Nurses Association (HPNA) and the National Hospice and Palliative Care Organization (NHPCO) began meeting regularly by conference call. Since then, three others organizations have joined the coalition: The Center to Advance Palliative Care (CAPC), National Palliative Care Research Center (NPCRC) and National Association of Social Work (NASW). Over the years, the Coalition has met monthly to discuss regulatory and legislative issues, identify emerging trends and issues that cut across the field, and share information regarding the activities within each organization. In-person meetings are also held at least once a year.

During the most recent meeting, the Coalition reaffirmed its purpose and mission which is focused on providing national leadership to assure the availability of services and support for a broad range patients and families facing life-limiting illness.
Considerable discussion also centered around sensitivities surrounding language and consistent inclusion of key concepts and care settings when addressing on important issues, particularly those of interest to the general public and policymakers. The group agreed to use the inclusive phrase “hospice and palliative care” when describing the work of the coalition, and when taking action on behalf of the coalition on related activities and goals.

Participants in the recent meeting included: Ron Crossno, Sean Morrison and Steve Smith from AAHPM; Carol Sieger, Amber Jones and Diane Meier from CAPC; Susan Cox, Todd Hultman and Judy Lentz from HPNA; Betsy Clark, Stacy Collins and Chris Herman from NASW; Gretchen Brown, Judi Lund Person and Don Schumacher from NHPCO. Sean Morrison also represented NPCRC. Additional public policy staff and consultants joined the meeting in the afternoon to discuss collaborative efforts related to advocacy.

Those assembled also clarified the coalition would accomplish its mission by:

  • Identifying and supporting a common agenda relating to public policy, education and research; and;
  • Sustaining and enhancing access to high quality services that honor patient and family health care decisions
  • Creating opportunities for collaboration and communication among members, staff and volunteer leaders whenever possible and appropriate

Leaders from the coalition agreed the meeting was very productive and remain committed to continuing to work together to improve quality of life for patients and families living with serious and/or life-limiting illness in all settings.

Eating Out and Activities in Vancouver

AAHPM and HPNA members and staff are getting excited for the 2011 Annual Assembly in beautiful Vancouver. As you may remember, last year, we posted our favorite dining out spots in Boston. Now we would like to know, those of you from or who have visited Vancouver, what do you recommend? Leave a comment and share some tips.

Thanks, and we look forward to seeing you there!

Concurrent Palliative Care-Peace of Mind in the Setting of an Uncertain Prognosis; Part 2

This is Part 2 of a multi-part series.

Approximately 1 week into her ICU stay, when my mom wasn’t making any progress on ventilator weaning, I was called by the palliative care team asking if they should “formally” consult. They had been visiting daily but not officially consulting – introducing themselves as “Jean’s friends” – who happened to be from palliative care. The ICU attending had tacitly agreed to the consult, telling the palliative care team, “whatever Jean wants”. My initial reaction was no, we didn’t need that, we knew that she potentially could have a poor outcome and were talking openly about it. If anything, I told the palliative care team, my dad needed a ray of hope, not a discussion about the “what if’s”. It was an eye-opening moment for me – to consider the “meaning” of requesting an official palliative care consult and to confront my own perceptions and biases, despite intellectually knowing better. Was I falling into the same “it’s not time yet” mindset that frustrates us so frequently as palliative care professionals? Why would making it “official” be any different from the daily visits that the team was already doing? How would my dad and my siblings perceive my request for an “official” palliative care consult? Would they think that I had “given up” by recommending a palliative care consult? Why didn’t I trust what we do so well in palliative care – starting with assessing the patient (if able) and family understanding of the current situation and addressing identified needs? Why couldn’t palliative care be as much about “hoping for the best” as it is about “planning for the worst”? I told the palliative care team that they needed to “hit me over the head” if I was in denial or not thinking rationally about this clearly reasonable request.

Why did this question give me such pause? At the time of her hospital admission, my mom did not have a terminal diagnosis. While she clearly had a chronic disease, it was just that, chronic. She wouldn’t have been described as having an “advanced illness” or a “serious illness” –phrases that we use in describing the target population for palliative care. In fact, despite her Parkinson’s diagnosis, she was quite functional, both physically and cognitively. Her current situation was thought to be more due to a medication reaction than to her underlying disease process. That said, here she was in the ICU, failing to wean from the ventilator. She was the epitome of an “uncertain prognosis”. Ultimately, I agreed to an “official” palliative care consult – both to legitimize the visits that they were already making and recognizing that even as a palliative medicine expert, I had significant “blind spots” when it became personal, not realizing the unspoken assumptions and perceptions that are associated with palliative care. And, as it turned out, the palliative care team, after visiting with my dad that same day decided not to formally consult, continuing to visit as “Jean’s friends”, deciding that they would do more good in maintaining that relationship than in announcing that, given my mom’s potentially grave prognosis, they were now “officially” consulting.