Archive for August, 2014

The Coleman Palliative Medicine Education Program

Recognizing the importance of palliative care service and the shortage of trained palliative care providers, the Coleman Foundation of Chicago awarded a grant to the Chicagoland Palliative Medicine Physicians’ Collective to train medical and interdisciplinary providers at hospitals across the Chicago area.

The Mission
Improve the quality of palliative care services at hospitals in the Chicagoland area

Improve patients’ and families’ access to palliative care services

Build a supportive network of palliative care providers across Chicagoland

Coleman Palliative Medicine Fellows
20 existing fellows will become junior mentors

25 physicians, advanced practice nurses, social workers & chaplains will be accepted into cohort 2, 2015-2017

Faculty and Mentors
Interdisciplinary mentors from medicine, nursing, chaplaincy, and social work

Expert clinicians, educators and researchers in palliative care representing 10 10 leading academic medical centers, community-based hospitals, health care systems and hospices in the Chicagoland area

The Fellowship
A 2-year training designed for health care professionals consisting of bi-annual workshops focused on skill-building, one-on-one mentoring, direct observation, e-learning. Fellowship mentoring centers on creating, implementing and evaluating a sustainable practice improvement project.

To learn more about the program and how to apply please click on the following link to the program website http://colemanpalliative.uchicago.edu/

Applications are due November 1, 2014.

Sean O’Mahony MB BCh BAO, MS
Section Director Palliative Medicine
Medical Director Inpatient Services Horizon Hospice and Palliative Care Organization
Associate Professor, Department of Internal Medicine, Rush Medical College
Associate Professor, Department of Community, Systems
and Mental Health Nursing, Rush University College of Nursing

Stacie K Levine MD, FAAHPM Associate Professor Co-Director Palliative Medicine Fellowship Director, Hospice and Palliative Medicine University of Chicago Medicine

Food and the Dying Patient

I’m at the Intensive Board Review course in Boston and in the middle of a whirlwind of learning. Dr. Joseph Shega’s lecture on Dementia and feeding tubes provided excellent clinical evidence to support my article in yesterday’s New York Times Well Blog post, Food and the Dying Patient

By Jessica Nutik Zitter, MD

Highlights of the August Issue of the Journal of Pain and Symptom Management

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

Highlights of the August issue include all the papers from the
Special Section on Studies to Understand Delirium In Palliative Settings (SUNDIPS)

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

How high to set the bar? Debates over TJC standards are healthy and familiar

The Joint Commission has proposed “enhancements” to the advanced certification requirements for palliative care programs and has requested comments by August 21, 2014 via online survey. A healthy debate about some of the new requirements is taking place on AAHPM listservs and social media platforms. I love seeing the passionate concerns about how best to define high quality palliative care programs. Some of the themes that have emerged remind me of debates at other points in our young history as field. I thought it might be useful to reflect on a few of the past points when the field had to draw a line in the sand and say “this is what good palliative care looks like.”

In the mid ‘80’s the initial hospice Conditions of Participation (COP) laid out in fine detail what was required to be a hospice that could get Medicare reimbursement. Some hospices passionately resisted Medicare certification, feeling that the rigidity in the COPs would negate the “hospice spirit.” But it is worth noting that those initial Conditions of Participation enshrined certain aspects of the “hospice spirit” that were revolutionary for health care at the time, notably the emphasis on interdisciplinary care planning, the requirement for meaningful volunteer participation, and the requirement for bereavement follow up for families.

In the early and mid 2000’s, we had a series of debates about standards for certification of physicians (lots of concern about whether requiring two years of experience was too high a bar for entrance for the old ABHPM exam – or not high enough), accreditation of fellowship programs (with actual raised voices – if I remember correctly – around the issues of how much time in a hospice rotation and how many home visits should be required for trainees), and articulation of the competencies for hospice and palliative medicine specialists.

All of these processes for setting standards shared a common challenge:
finding a balance between two competing goals. On the one hand is the goal for clearly stipulating each structure, process and outcome that effectively enhances the quality of patient care. On the other hand is the need to be parsimonious so that the requirements, including the reporting burden, are achievable and reasonable.

People arguing for a tougher standard usually claim its necessity for ensuring the quality of care, while people arguing for a lower standard usually point out how difficult (or impossible) the standard will be to meet for the “average” program. I remember during the debate about fellowship accreditation standards that one of our very wise leaders pointed out that a higher standard was actually a very useful tool that program leaders could use in the fight to get resources for a program. This fellowship director – whose program at the time did NOT have a hospice rotation – said that he had been fighting to get a hospice rotation but couldn’t get approval from various GME office higher ups. There were too many objections about sending trainees out of the institution, vetting the hospice faculty, etc. But if the accreditation requirements specified a hospice rotation – whether of one month or 6 months (the amount under debate at the time) – he would easily get his GME office on board. “If it’s required, they’ll do it.”

I think it would be useful to keep this in mind when thinking about some of the proposals for TJC standards that may be very difficult for current programs to meet. For instance, some argue that palliative care programs should be able to provide consults 24/7, not just during business hours. This is consistent with the National Consensus Project standards, but is not the current norm for most hospital-based palliative care programs. And it would be a VERY difficult standard for small programs to meet. N of 1 programs would find it virtually impossible, unless they got very creative and worked out call sharing arrangements with other services. Or argued with the hospital C-suite – backed up by stiff TJC requirements – that they HAVE to expand and hire more palliative care service staff.

The realities are that workforce shortages and financial limitations may make it very difficult for many programs to achieve a standards bar set at a high level. But the very fact of setting the bar so that it is a challenging goal to shoot for, and not just an easy ratification of existing practices, may help raise the level of the entire field. In the push-pull between the highest standards and easy achievability, there is some just right place in between. I think we would do well as a field to continue our history of setting the bar high enough for a challenge – and then working to make sure all programs can get there. The guiding question – would I want to be cared for in a program like this? – won’t steer us wrong.

I invite others to comment and share their perspective, including on the TJC’s proposed revisions.

Dale Lupu
Consultant, Quality Initiatives
American Academy of Hospice and Palliative Medicine

AAHPM participates in ABIM MOC discussions

On July 15, we had the opportunity to participate in a Summit convened by the American Board of Internal Medicine (ABIM) and attended by ABIM leaders and 26 societies representing both primary internal medicine and medicine subspecialties. The Summit was scheduled in response to the dissatisfaction with the ABIM Maintenance of Certification (MOC) program expressed by the greater internal medicine community. Stakeholders were provided the opportunity to share feedback from their constituents and discuss the MOC program. We presented the somewhat unique concerns of hospice and palliative medicine specialists:

  • Hospice and palliative medicine has 10 co-sponsoring boards with varying expectations for MOC making the creation and approval of MOC activities that are relevant to HPM practitioners a challenge.
  • At present, there is a lack of reciprocity between Boards for MOC activities.
  • There is additional strain created on our already limited workforce by the requirement to maintain primary board certification. This is particularly onerous for those who practice HPM full time, as the vast material tested on the primary exam may be irrelevant to their practice.

A brief word of context: Since Hospice and Palliative Medicine received formal recognition as a medical subspecialty by the American Board of Medical Specialties (ABMS) in 2006 and the American Osteopathic Association (AOA) in 2007, AAHPM has been meeting with and advocating for the needs of the Hospice and Palliative Medicine (HPM) community related to certification, maintenance of certification (MOC) osteopathic continuous certification (OCC), and fellowship programs.

The American Board of Internal Medicine (ABIM) has been evolving its MOC program and there has been a great deal of communication between the ABIM, ABIM specialties and subspecialties, and ABIM physicians in the last few months. On July 10, ABIM announced several changes to the MOC. ABIM stated that it will:

  • Increase flexibility on deadlines. ABIM’s Board agreed to create a year “grace period” for those who have attempted but failed to pass the MOC exam.
  • Ensure transparency of information. In response to questions raised about ABIM’s governance and finances, they have added information to their website and ABIM’s 990s are publicly available on Guidestar.
  • Ensure a broader range of CME options for medical knowledge/skills self-assessment (Part 2). To reduce redundancy and give physicians credit for relevant assessment activities in which they are already engaged, ABIM will align its knowledge assessment requirements and standards with already existing standards for certain types of CME products and providers.
  • Provide more feedback regarding test scores. The ABIM agreed to provide more in-depth, actionable feedback on individual performance on all exam score reports by 2015.
  • Evolve the “Patient Survey” requirement to a “Patient Voice” requirement. This requirement focuses on a variety of structured mechanisms to hear from patients. In addition to patient surveys, educational and training programs in patient communication, participation in patient/family advisory panels, and use of shared decision-making tools, activities which many of our members may already be doing, may also meet the patient voice requirement.
  • Reduce the data collection burden for the practice assessment requirement. ABIM is re-designing the process to provide additional pathways to meet the requirement and focus more on measurement and improvement activities.

In a letter dated July 28, 2014, ABIM summarized the major issues presented at the Summit and reiterated that the purpose of the ABIM is to “issue a publicly recognized credential that indicates an individual has met professionally-determined standards in a defined discipline”. Specifically, they agreed that the secure exam “must evolve” and they announced plans to form a committee to explore how to move forward. Formal mechanisms for society input will be developed. Addressing extremely negative feedback related to Part 4 (self-evaluation of practice assessment), the ABIM promised dramatic changes over the next 12-24 months.

We are encouraged to learn of ABIM’s proposed changes to its MOC program and will continue to work closely with the ABIM to improve the MOC program. We welcome your comments and concerns . Your feedback enables us to accurately represent the concerns of our members. Please share your thoughts with us via the AAHPM blog.

Tara Friedman, MD, FAAHPM, AAHPM Board Member
Holly Yang, MD, FACP, FAAHPM, AAHPM Board Member