Palliative programs model patient-centered care

Now that palliative care has become part of the mainstream of modern medical care, health care organizations are looking to it as an important puzzle piece in the evolution toward more coordinated care. By its very nature, the effort to give seriously ill patients the pain and symptom control and social services they and their families need, no matter the setting, is patient-centered care.

The winners of the 2013 Circle of Life Awards, honoring innovation in palliative and end-of-life care, illustrate this evolution. The Denver Hospice pursues relationships with health plans to provide palliative care as an insurance benefit. Mount Sinai Medical Center's Hertzberg Palliative Care Institute is creating a new vision of inpatient palliative care that provides all clinicians with the tools to provide patients and their families with what they need. And UnityPoint in Iowa and Illinois, rapidly identifies best practices and replicates them throughout the system, while using palliative care as a major feature of its accountable care projects.

The 2013 awards are supported, in part, by the California HealthCare Foundation, based in Oakland, and Cambia Health Foundation, based in Portland, Ore. Major sponsors of the 2013 awards are the American Hospital Association, the Catholic Health Association of the United States, and the National Hospice and Palliative Care Organization and National Hospice Foundation.


|WINNER | The Denver Hospice

It's often a struggle to pay for palliative care. But Kaiser Permanente members in the Denver area have had it covered for the past 12 years. That's because the Denver Hospice worked with Kaiser to create the first palliative care benefit in the country.

"We've had a very pioneering culture," says Bev Sloan, CEO of the Denver Hospice, citing the looming Rocky Mountains as inspiration. "It's a progressive culture within our organization. There's an opportunity to try new ideas in the West."

The Denver Hospice's fearless culture of innovation has produced partnerships that bring hospice and palliative services to a wide variety of people who might not otherwise have access to them. The safety net provider for end-of-life services in the Denver metro area, the Denver Hospice, established in 1978, never turns away a patient, and it provides services at home, in assisted living and skilled nursing facilities, and in hospitals.

The Denver Hospice's palliative care program — Optio Health Services — cares for seriously ill patients, including those undergoing curative treatments, with a team of nurse practitioners, social workers, chaplains and registered nurses backed up by after-hours telephone and visit support. Optio's Palliative Inpatient Consult program provides consultation by palliative care physicians in the acute care setting. Optio's Care Support program contracts with insurers and physician groups to expand services to members for advanced illness management.

Most striking about the hospice has been its interest in partnering with a variety of organizations in innovative ways:

The Denver Hospice has a 20-year relationship with Kaiser Permanente that has served more than 10,000 patients with hospice as well as outpatient palliative care. "People would always say outpatient palliative care is a bad business model," says Janelle McCallum, hospice chief operations and quality officer. "But it was so needed by our community, and Kaiser in Colorado has been such a good partner; they said very early on that outpatient palliative care is important, so we're going to help pay for it. That was totally revolutionary at the time."

The Veterans Administration has worked with the Denver Hospice to identify special needs of veterans, who make up 31 percent of the hospice's patients. "We've found that if they saw combat, it ends up complicating the end of life," explains McCallum. "Their experience starts resurfacing."

Optio works with Colorado Access, which provides services to people dually eligible for Medicare and Medicaid, providing complex case management to help avert unneeded hospitalizations, including a pilot offering home visits with a psychosocial focus. "For instance, we'll know a certain patient has a problem on a Friday night when her anxiety goes up, so we would note to call her to see how she was doing," explains McCallum.

Those unusually broad arrangements with payers and provider groups "position us for the future as we look to move away from fee-for-service medicine and the fragmentation our care system creates today, to more coordinated care," Sloan says. "Advanced illness and palliative care programs really help fill in those gaps as a major form of coordinated care for people with very serious illness."


|WINNER | Hertzberg Palliative Care Institute

Palliative care is in demand at Mount Sinai Medical Center — so much so that the 1,000-bed academic medical center in Manhattan is moving toward the concept of "primary palliative care."

As the inpatient palliative care program expanded to two consultation teams, with a third in development, its leaders realized that to truly meet the needs of all seriously ill patients and their families, they couldn't keep adding teams indefinitely.

So they are developing palliative care order sets and protocols for hospitalists, primary care physicians and specialists, and educating physicians on palliative care skills — a particularly effective strategy in a teaching institution where residents, fellows and attending physicians "grow up" with the palliative care team. "We're at a big turning point," says Jay Horton, R.N., director of the consultation service. "We need to transform how we think about inpatient palliative care."

A key part of this transformation is the Wiener Family Palliative Care Unit, a 13-bed inpatient palliative care unit where patients with complex needs can be cared for around-the-clock by a dedicated team. Half the beds have Central Park views. Creating it took 10 years of planning given the hospital's competing needs and limited space. "The hospital gave up quite a lot of beds to have our palliative care unit built," says Emily Chai, M.D., associate director of the hospital's Hertzberg Palliative Care Institute.

The PCU, like the consultation teams, is staffed by an attending physician, nurse practitioner, social worker and a postgraduate fellow. Additional supportive care is provided by a chaplain, registered nurses, six licensed massage therapists, a yoga specialist and an art therapist.

The Hertzberg Institute also provides an active and expanding community palliative care program. After discharge, patients can be followed by the team at the Martha Stewart Center for Living outpatient facility. And, as of February 2013, a palliative care team is embedded in the new Ruttenberg Treatment Center of the Tisch Cancer Institute providing palliative care to patients and their loved ones in conjunction with regular oncology care. Hertzberg also maintains close relationships with the Mount Sinai Visiting Doctors Program, which provides care to homebound adults in Manhattan, and the Visiting Nurse Service of New York's hospice program.

Education of new palliative care clinicians and others at all levels of training is central to Hertzberg's mission, with one-week rotations for all third-year medical students, a palliative care fellowship with seven spots each year and a number of continuing education opportunities for all types of medical professionals.

As Hertzberg looks to the future, Director R. Sean Morrison, M.D., sees tremendous opportunities to further improve care for seriously ill patients and their families through new payment mechanisms under the Affordable Care Act. "Palliative care is one of the few proven models that addresses the triple aims of health care — improving quality, improving satisfaction and reducing costs. We are optimistic that emerging reimbursement models that favor coordination of care and community-based care will support further integration of palliative care into the fabric of our health care delivery system," Morrison says.


|WINNER | UnityPoint Health

Just a few years ago, innovative palliative care programs were germinating in several communities served by Iowa Health System, but the system didn't have a unified approach. Using data analysis and a commitment to collaboration, the system, now known as UnityPoint Health, Urbandale, Iowa, has built a model based on what it's learned, and disseminated it across a far-flung system that includes 280 physician clinics, seven home health care regions and 26 hospitals in Iowa and Illinois.

"We started in 2005 with very small programs, and they weren't across the continuum," explains Monique Reese, R.N., chief clinical officer of UnityPoint at Home. "We now have programs across the continuum and across the region, too."

An examination of two years of palliative care metrics found that the best outcomes seemed to come from a hospital/home care/clinic collaboration with a dyad leadership of a physician and a clinical administrative, explains Lori Bishop, R.N., executive director of palliative care and hospice for UnityPoint at Home. "Instead of having the patient move between an inpatient program and an outpatient program, our intent was to have one program," Bishop says.

When something works, UnityPoint Health is quick to share it. "We use data to identify evidence-based practices and then share those across our palliative care programs," explains Reese. The before-and-after data on patient-centered, team-based care show dramatically improved outcomes in patient satisfaction, health status, symptom management and goals of care identified. "Financially we're experiencing a bending of the cost curve."

Over the past two years, the system has built a sharing structure so that palliative care clinicians and program administrators from throughout the system can compare notes on a monthly or quarterly basis to improve care. "We really try to look at best practices in each site and share information so we're all on the same page and not reinventing the wheel," says Kimberly Shadur, R.N., palliative care coordinator for UnityPoint Hospice in Des Moines, Iowa.

UnityPoint Health recognizes the potential for palliative care to mesh well with evolving reimbursement mechanisms that reward coordinated care. However, it's still a largely fee-for-service world, so providers that get out ahead of the coordination trend are likely to take a financial hit, at least for a while. UnityPoint Health has been willing to accept the temporary loss resulting from reduced hospitalizations for seriously ill patients because it's better for the patients. "We knew we were making an investment in the future," says Reese. "We were willing as a system to take that leap of faith. We felt it would promote the best outcome for the patient and family, and leadership was on board with that."

The system is actively participating in Medicare payment reform projects, such as the Pioneer Accountable Care Organization program, which is taking place at UnityPoint Health's Fort Dodge, Iowa, location. Nadine Schlienz, R.N., manager of the palliative care program at Fort Dodge, said palliative care is essential to the ACO model. "We're showing Medicare we can deliver health care at a more affordable cost to them. We're working to show we can take care of patients in a home setting, wherever it may be."


Citations of Honor

• Hospice of Dayton (Ohio)

Hospice of Dayton emphasizes quality of life, making extensive use of complementary therapy and spa services such as massage, and adding new services in response to patient and family needs.

• Nathan Adelson Hospice, Las Vegas

A nonprofit hospice in a for-profit market, Adelson provides hospice and palliative care services in local hospitals, reaches out to the Latino community, provides significant charity care and raises funds by marketing its innovative ideas to others.

• Veterans Health Administration Hospice and Palliative Care Program

The nation's largest integrated health system has extended palliative care services to every region, learns from the data in its electronic health record system and effectively shares best practices among local teams.

• Gundersen Health System, La Crosse, Wis.

This large Midwest health system provides palliative care across the continuum, uses advanced care planning with older adult patients and scans the electronic health record daily to identify patients with advanced illness who may need palliative care.

• North Shore University Hospital, Manhasset, N.Y.

The palliative care team reaches 65 percent of patients who die during hospitalization; the program emphasizes research and extending palliative care to home and nursing facilities.


ABOUT THE AWARD

The Circle of Life Award honors programs that are striving to provide effective, patient-centered, timely, safe, efficient and equitable palliative and end-of-life care; show innovation in approaches to critical needs and serve as sustainable, replicable models for the field; and are actively working with other health care organizations, educational and training programs, and the community. For complete criteria and other information, visit www.aha.org/circleoflife.