Howard Epstein, a hospitalist at Regions Hospital in St. Paul, MN, spent nearly 2 years planning an inpatient palliative care consultation service for Regions before its launch in January of this year. A multidisciplinary advisory committee met monthly to help with the planning, and Dr. Epstein, the embryonic program’s medical director, went before the hospital’s administration to make the clinical and financial case for supporting it.
“What we’re trying to do is to take the basic interdisciplinary approach pioneered in hospice and move it upstream,” to help relieve suffering in seriously ill patients before they need or qualify for hospice care, he explains. “I just knew I wanted to incorporate it into a hospitalist model,” and into the Hospitalist Services Division’s weekly block schedule.
After the service was launched, it became clear that the schedule did not allow for the significant time commitment required to do palliative care, so a new approach is planned for July. Dr. Epstein and 6 other hospitalists participating in the palliative care service will divide up weekly blocks of time. Half of their duties while on service will be devoted to palliative care and the other half to covering 1 hospital unit as a hospitalist, rather than the usual 2 units for hospitalists at Regions.
The palliative care service at Regions, which includes a half-time chaplain and social worker and a full-time nurse practitioner, responds to consultation requests by doctors and nurses from all of the hospital’s adult services. The service also admits patients from HealthPartners’ affiliated hospice program when they are hospitalized at Regions for short-term symptom management or respite care.
Key to long-term success lies in documenting improved clinical outcomes, patient, family, and provider satisfaction, financial savings, and enhanced patient throughput. “I’m optimistic we’ll be able to demonstrate significant value, but if we can’t, we’ll be hard-pressed to get continued support,” he says. This challenge, he adds, is similar to what the hospitalist service at Regions faced when it was launched in 1998.
Palliative care is not a new concept in medicine, but it has enjoyed dramatic growth in recent years. The American Hospital Association estimates that 17% of community hospitals and 26% of academic teaching hospitals in the United States now have either a palliative care consultation service or a dedicated unit, although the former is more common because it can be established with a smaller fiscal outlay.
Palliative care aims to relieve suffering, broadly defined, for patients living with chronic, advanced illnesses. State-of-the-art pain management is a major emphasis for the interdisciplinary palliative care team, but so are addressing the patient and family’s emotional, psychological and spiritual concerns related to the illness and offering guidance for making informed treatment decisions that reflect their values and goals for care. Palliative care services generally target all patients with advanced illness from the point of diagnosis, simultaneous with any other medical treatment regimens.
Two Medical Fields Growing Together
“I believe hospitalist practices and palliative care services are of necessity growing closer together,” says Susan Block, codirector of the Harvard Medical School Center for Palliative Care in Boston, MA. The Harvard Center provides intensive palliative care training for clinicians who also have an interest in teaching.
“If you run a palliative care consult service or a palliative care unit, you are operating much like a hospitalist, with a focus on hospital systems and workload issues, communication, and getting people out of the hospital,” Dr. Block says. At the same time, most hospitalists deal with end-of-life issues and the challenges of relieving symptoms such as pain, delirium, or anxiety every day, whether they view their role in those terms or not.