Posts tagged palliative medicine

JPSM Call for QI Papers Closes April 15

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).

Appreciating Our Volunteers

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

30/30/30 Campaign to Improve Late-Life Care

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.

Dr. Allison Lauber Shares a Unique and Inspiring Story about the Board Exam

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!

How Often Should Patients with Advanced Illness Be Visited By a Physician?

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.

Peds SIG Offers New Avenues for Involvement in the Field

Although it was painful to get up so early on the final day of the AAHPM Assembly in Vancouver, it was completely worthwhile to attend the meeting of the Pediatrics Special Interest Group (SIG). Over the years that I’ve attended this meeting, it’s been amazing to watch the evolution of interest and attendance in our SIG, and the parallel explosion of pediatric education, research and advocacy opportunities.

In 2007, our statewide pediatric palliative care (PPC) network OPPEN (Ohio Pediatric Palliative and End-of-life care Network) organized a national conference as a follow-up to the National Hospice and Palliative Care Organization’s (NHPCO) pediatric conference in Dearborn, Michigan in 2004. These efforts were organized precisely because there was no place for PPC providers to go to find educational and research information and to network with colleagues; most national conferences had only occasional, if any, pediatric content. Fortunately, that has certainly changed!

For the past few years, the AAHPM has offered greatly increased pediatric content at the Assembly, with pediatric sessions in almost every concurrent slot, as well as large numbers of pediatric paper presentations (which are often award winners). Pediatric representation exists throughout the organization, from workgroups and committees through the Board of Directors.

Similarly, NHPCO has been offering a pediatric track at its Clinical Team Conference for several years now, and its advisory group ChiPPS (Children’s Project on Palliative and Hospice Services) has expanded, undergone strategic planning, and taken on a leadership role in equipping hospice and palliative care organizations to care for children and in working closely with NHPCO in its advocacy and policy activities (www.nhpco.org/pediatrics).

The American Academy of Pediatrics (AAP) has also jumped on the PPC bandwagon, with the establishment of the Section on Hospice and Palliative Medicine. This group is focusing primarily on policy and educational activities, including opportunities for scholarly activity through the AAP’s main meeting, the National Conference Exhibition. The Section maintains 2 listservs that boast healthy discussion about many aspects of our field, 1 for members and 1 for any interested parties; Affiliate Membership is possible for non-physicians as well (www.aap.org; check out the web page soon for a more expanded discussion of each of these national opportunities for PPC involvement and commitment).

The Center to Advance Palliative Care has recently increased its pediatric focus too. Last fall, the annual conference included a pediatric track for the first time, and that will continue this year. Palliative Care Leadership Center tools and training for programs interested in starting or growing a PPC or hospice program have been available through a number of different sites for years; in 2008, 2 pediatric-specific sites were added (Akron Children’s Hospital and Children’s Hospitals and Clinics of Minneapolis) and a new pediatric curriculum was developed (www.capc.org).

And there are other groups involved with PPC as well. A few more highlights include:

  • PEPPERCORN, the Pediatric Palliative Care Research Network, a dedicated group of researchers from a number of sites across North America who are working individually and collaboratively to advance the science of PPC
  • The Hospice and Palliative Nurses Association (www.hpna.org), which has successfully developed a pediatric nursing certification examination in hospice and palliative care, and is also developing accompanying educational material
  • The National Networks for Pediatric Palliative Care (www.network4pedspallcare.org), a grassroots effort focused on developing a web-based clearinghouse of programs and information for families and providers.
  • The Pediatric Hospice and Palliative Medicine Competencies Project, a group of PPC leaders who have been working with the original HPM competencies document and authors to create a companion resource for pediatrics; importantly, the AAHPM’s Board of Directors approved support for this project at this year’s board meeting.

During this time, the Academy’s SIG has continued to meet and grow. In the last few years, we’ve become more organized, along with all SIGs in the Academy which are receiving more support through the new and expanded Communities model. We’ve developed an elections process, allowing a rotation of leadership and the opportunity for younger or newer folks in the field to become involved. This year’s Assembly featured a Pediatric SIG-sponsored session which was very well received. And there were a tremendous number of great suggestions for next year’s Assembly that were generated at the SIG meeting. Our next big push will be for a pediatric plenary!

In short, it’s a great time to be in pediatric hospice and palliative care. Seeing colleagues, learning about many new avenues to become involved in the field, talking about challenging and uplifting situations, sharing wisdom and lessons learned, and literally catching the contagious excitement among us were just a few of the reasons to get out of bed on Saturday morning for the SIG meeting. Hope to see you there next year in Denver!

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.

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.

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.