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Palliative Care Services Offer New Horizons for Hospitalists


 

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.

Stephanie Grossman, a hospitalist at Emory Healthcare in Atlanta, GA, says she discovered personal satisfaction as a young physician in having meaningful conversations about care goals with seriously ill patients and leading family conferences, despite the time pressures of the job. The head of the hospital medicine service at Emory, Mark Williams, MD, told Dr. Grossman there was a name for what she enjoyed doing: palliative care. He encouraged her, along with colleague Melissa Mahoney, to obtain additional training in developing such a program, starting with a 2003 conference in San Diego sponsored by the Center to Advance Palliative Care.

“I came back from San Diego feeling swept away by how it really was possible to develop a financially feasible program,” says Dr. Grossman. Back at Emory, she and Dr. Mahoney joined a palliative care task force formed by Dr. Williams, with representatives from geriatrics, nursing, social work, chaplaincy, finance, and administration. This group provided input for a business plan for the palliative care service that will start in September at Emory Crawford Long and Emory University hospitals.

The 2 hospitalists, who have become certified in palliative medicine, will divide a full-time position as codirectors of the inpatient palliative care service in alternating monthly blocks, along with additional teaching responsibilities. Their 4-year plan is to add additional staffing as the program grows and to work with a geriatrician to develop a palliative care fellowship program. The palliative care team, including a nurse, social worker, and chaplain, will conduct daily palliative care rounds and biweekly interdisciplinary case conferences at the 2 hospitals.

“We have a nurse practitioner involved to help us coordinate between the 2 sites. We’ll go to various departments and do some grand rounds to introduce and market the program,” Dr. Grossman notes. In addition to practicing a style of medicine that offers deeper personal interactions with patients, she is excited to be part of creating a new program. However, she emphasizes the importance of having an executive champion within the hospital who understands financing, institutional politics, and how to recruit other champions. “We’ve been lucky to enjoy the support of Dr. Williams and [Emory Chief Operating Officer] Pete Basler. Dr. Mahoney and I have been working with hospitalists for several years, but our work has all been clinical,” she says.

Another challenge for hospitalists interested in pursuing palliative care include the need to make sure their new responsibilities are not just an add-on to a full-time job. The hospital needs to commit resources for planning and implementing a palliative care program, including a percentage of the hospitalist’s time, Dr. Block says. “Zero FTEs is not viable in the long run,” she adds.

Physician billing for palliative care consults can help offset the costs of running a service, but it is unlikely to break even on billing alone, says Eva Chittenden, a hospitalist and palliative care physician at the University of California-San Francisco, which has operated a palliative care service since 1999. Dr. Chittenden is also part of the Palliative Care Leadership Center at UCSF, which offers 2-day intensive training programs 4 times a year for hospital teams that want to start or strengthen inpatient palliative care services.

In most cases, palliative care requires financial support from the hospital, although it’s not difficult to justify that support by showing cost avoidance, reduced lengths of stay, and improved clinical outcomes, with the help of tools developed by the Center to Advance Palliative Care, Dr. Chittenden says. Program development also challenges the hospitalist’s leadership and marketing skills.

A Process of Growing Involvement

“What often happens with hospitalists is that they start out exploring palliative care, and it becomes very compelling,” Dr. Block adds. “The more competent you get at it, the more compelling it becomes. They find deeper meaning in their work. And then they’re hooked.”

A hospitalist can seek additional training and then incorporate palliative care tools, concepts, and perspectives into his or her daily work. An interest in palliative care may lead to involvement with the hospital ethics committee, a seat on a palliative care advisory committee, or a role in standards or protocol development, as well as pursuit of specialty certification in hospice and palliative medicine.

Although hospitalists may be obvious candidates to participate in more formal palliative care program development, “incorporating palliative care into a routine hospitalist practice is not a trivial thing,” Dr. Block adds. For starters, it requires additional training. “Most hospitalists don’t have the competencies to practice expert palliative care if they don’t seek them out,” she says. But the opportunities are increasing, with growing palliative care fellowship opportunities nationwide.

Two hospitalists at Chandler Regional Medical Center in Chandler, AZ, are among the 4 physicians who serve on that facility’s 12-member interdisciplinary palliative care team, attending weekly team meetings to review active cases and brainstorm program development. Both have attended national palliative care conferences, reports the palliative care service’s nurse practitioner, Donna Nolde. The service consulted on 89 patients in March, and about 70% of those referrals came from hospitalists.

“As hospitalists, we often deal with issues of death and dying,” especially when working in the ICU or with referring oncologists, notes Chandler’s Mahmood Shahlapour. “We can sometimes step back and see the big picture when other doctors have trouble letting go.” Dr. Shahlapour believes palliative care is a logical extension of good internal medicine and will eventually become a bigger part of the training of internists.

An atypical path to palliative care is that of Glenda Hickman, MD, who was a hospitalist for the Denver, CO–based HealthONE system until one of the system’s hospitals asked her to take on the role of freelance palliative care consultant. Hickman, who also works part-time for Hospice of Metro Denver as a team medical director and picks up lecturing and teaching assignments, accepts consultations from 3 HealthONE hospitals and bills third-party payers for her consultations. Her husband is office manager and biller for her home-based business, and she carries a cell phone and pager to promptly answer referrals.

“I had a reputation for the touchy-feely aspects of medicine at the hospitals where I worked,” Dr. Hickman relates. “Dying patients would often get referred to me.” Based on her interests, Dr. Hickman sought training in palliative care, but she found it difficult to juggle with her full-time job as a hospitalist. “The heart of palliative care in a hospital is talking with patients and families. These conversations take a long time,” she says. When the hospital asked for her help in meeting its JCAHO requirements in pain management and palliative care, Dr. Hickman was willing to explore a model for how she could hang out a shingle as a solo practitioner.

Business is growing, although the workload fluctuates widely. However, while Dr. Hickman works alongside social workers and chaplains at the hospitals, the biggest drawback has been the lack of a formal, interdisciplinary team. “This is high-maintenance, high-emotion work. It can be a big drain, and I don’t have a designated team with which to share the burden. My goal is to run a full palliative care team for the hospital,” she says, and there are signs that HealthONE eventually may move in that direction.

“It’s not that hospitalists can’t do palliative care. I did. I was so drawn to it and to trying to do it right, which meant I was trying to do 2 jobs at once,” she adds. Hospitalists can also participate by recognizing when their patients need the extra attention of a palliative care specialist. “Identifying who those patients are is a huge skill by itself.”

Resources for Getting Started in Palliative Care

The Center to Advance Palliative Care (CAPC) at Mount Sinai School of Medicine in New York City offers a comprehensive national resource for palliative care development in hospitals, including how to make the financial case. Its next national seminar is October 17 to 19 in San Diego, CA. CAPC also supports 6 regional Palliative Care Leadership Centers, including one with a hospitalist emphasis at the University of California-San Francisco, scheduled to run through June 2006. For more information on CAPC’s resources and leadership centers, call 202-201-2670 or visit www.capc.org.

Larry Beresford can be contacted at larryberesford@hotmail.com.

Other Helpful Resources

  • For information on the Education in Palliative and End-of-Life Care (EPEC) curriculum, visit www.epec.net.
  • The American Board of Hospice and Palliative Medicine will offer its next specialty certifying examination in November of 2005. For eligibility or other questions, call 301-439-8001 or visit www.abhpm.org.
  • The American Association of Hospice and Palliative Medicine offers education and training resources, including an annual assembly scheduled for February 8 to 11, 2006, in Nashville, TN; visit www.aahpm.org.
  • Harvard’s Center for Palliative Care offers a 2-week intensive training course, with an emphasis on teaching, in April and November every year. For information, call 617-724-9509, send email to pallcare@partners.org, or visit www.hms.harvard.edu/cdi/pallcare/.
  • The Veterans Administration also offers palliative care resources, fellowship opportunities and other information; visit www.hospice.va.gov.

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