Tailoring Palliative Care for Small Communities Lyn Ceronsky DNP, GNP, FPCN Director, Fairview Palliative Care Palliative Care Leadership Center
Objectives 1. Identify the role of needs assessment and community characteristics for planning palliative care 2. Describe common features of successful models of palliative care in small communities 3. Discuss ways to develop your program to meet quality standards for palliative care 2
Why is Community-based Palliative Care Important Now? Changing Demographics * Aging population * Rising survival rates of person with debilitating chronic illness Economics of Health Care Demand for * High cost of care of patients with serious illness Community- based Palliative Care Patient Preferences of Health Care * Desire to be at home New Models of Health Deliver * Accountable Care Organizations * Medical Homes * Providers & health systems accepting risk 3
Key Characteristics of Community-based Palliative Care C+b+P+C Model C onsistent Across Transitions Services consistent across the many transitions expected with seriously ill patients: Philosophical transitions, disease-related transitions, locational & temporally dynamic transitions B roadly Available Services are available for people residing in community, with community defined as the summation of settings in which patients and loved ones live, work, play, and receive health care, both statically and during transitions. P rognosis-independent Services provided regardless of prognosis, diagnosis, or point along disease trajectory; not limited to payer-established prognostic thresholds or requirements of ongoing decline in functional status C ollaborative and coordinated Delivered through multi-disciplinary team who provide regular multi-domain assessments & comprehensive plans, & with whom patient interacts with before, during & between transitions 4
Complementary Principles Community-Based Design for Rural Palliative Health Care of the Characteristics Future * ➔ Consistent across ➔ Accessible transitions ➔ Affordable ➔ Across continuum ➔ Quality ➔ Prognosis independent ➔ Community based ➔ Collaborative and ➔ Patient centered coordinated 5
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What is a “Small” Hospital or Community? ➔ Critical access hospitals (25 beds or <) ➔ Small community hospitals (~100 beds +/-25 beds); may or may not have specialties (onc,surgery) ➔ Isolated hospitals ➔ Communities interested in building a palliative care program across the continuum 7
Growth of Palliative Care in Small Hospitals 22% of small hospitals (fewer than 50 beds) provide palliative care services 2011 National Palliative Care Research Center; data from AHA 2000-2009 8
Challenges ➔ Interdisciplinary team availability ➔ Board certified providers — difficult to find ➔ “We do this already” ➔ Characteristics of a rural setting ➔ Reducing cost and LOS isn’t important ➔ “We have a great hospice, so…..” ➔ Lack of clinical/financial models to replicate ➔ How do we assure quality palliative care? 9
Rich Benefits of Rural/Small Communities ➔ Relationships ➔ Existing processes for care ➔ Community support and accountability ➔ Flexibility and opportunity to align with local initiatives ➔ Preference of community members to receive care in home community 10
Successful Programs: Fertile Ground ➔ Sufficient local health infrastructure ➔ Having collaborative generalist practice and a shared vision of change ➔ Sense of local empowerment ➔ Keys to success are working in a small community, working together, and being community focused Kelley 2011 11
Alliance of Community Health Plan Palliative Care Program Criteria ➔ Critical Elements: – Interdisciplinary team – Access – Symptom management – Communications with Care System and to patients/families – Documentation 12
Steps in Program Development ➔ Needs assessment ➔ Develop operational and clinical model ➔ Education ➔ Measurement ➔ Financial ➔ Marketing ➔ Community partnerships ➔ Plan for growth 13
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What will we learn from a community assessment? ➔ Understand internal context (timing, patients, geographic area, revenue sources) ➔ Stakeholders (identify and quantify others’ perceptions and needs) ➔ Data: demographic, utilization, inventory providers and payers ➔ Synthesize and identify service gaps and desired outcomes, patient population and organizational readiness next steps 15
What problem(s) are addressed by palliative care? ➔ Use this question in your team discussions – Treatments not concordant with individual’s goals – Late recognition of dying phase – Pain not managed as well as possible ➔ Rationale for needs assessment – What has highest priority? – What do we have resources to address? – How can we start small and build? 16
Case Study #1: Community of Elm Creek (early phase) ➔ Hospital quality leader facilitated Community Needs Assessment ➔ Convened advisory group representing different health care entities; lead by family physician and SNF nurse ➔ Identified two priority initiatives: – Professional and community education – Care of patients with dementia 17
Elm Creek Priority Initiatives ➔ Education: – Health fairs, patient brochures “Ask About” – Advance Directives – Professional communication education (on line) ➔ Dementia: – Choosing Wisely: feeding tubes, accelerate care – Goals of care discussion at transition points 18
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Case Study #2 Rural Midwest Health Care System ➔ Population: Serve 40K, town 3000, 4 counties ➔ Critical Access Hospital (CAH) 25 beds ➔ Home care + hospice ➔ Rural Health Clinic with 4 satellite clinics ➔ Long Term Care (100 beds) ➔ Clinical staff: family physicians, mental health providers, some specialists 20
Rural Midwest Health Care System ➔ Hospital, Senior services, home care, outpatient ➔ IDT, case management, telephonic support ➔ Staffing: – RN case manager – Social worker – Pharmacist – Medical director, Family Medicine and HPM Board Certified – Mental Health Clinical Nurse Specialist – Spiritual volunteers from local faith communities 21
Revenue Sources ➔ Provider charges for usual face-to-face care in clinic, hospital, LTC, or home ➔ Insurance payer contract for unbillable visits by nurse, social worker, spiritual care ➔ Ability to demonstrate program capacity and quality outcomes for contract discussions ➔ Partnerships with VA system 22
Case 3: Memorial Hospital and Clinic ➔ APN-led, with collaboration from pharmacy, social workers and chaplains ➔ Patients seen in hospital and oncology clinic ➔ Built on education of medical and nursing staff ➔ Evolved to include 2 affiliated hospitals staffed with palliative care nurse 23
Financial Sustainability ➔ Existing revenue sources (home care, home visits) ➔ Contracts with payers (example: U-Care) ➔ Local philanthropy (+/-) ➔ Financial analysis supported by health system focus; offset by other programs ➔ Partnership with community agencies ➔ Use of technology to extend clinical expertise – Telephonic case management, telehealth 24
Case Study #4: Minnesota Rural Palliative Care Initiative (MRPCI) ➔ Multiple communities convened over two years ➔ Began with needs assessment ➔ Primary strategies: – Learning collaborative approach (IHI) – Use of domains of palliative care + NQF preferred practices – Focus on community capacity development – Small tests of change ➔ Multi-setting, multi-disciplinary teams ➔ Final Report: – http://www.stratishealth.org/documents/PC_Stratis_Health_MRPCI_Final_Report_2011_06.pdf 25
MN Rural Palliative Care Initiative ➔ Conceptual Framework: Community Capacity Development Theory ➔ 18 month learning collaborative ➔ Fairview Palliative Care + Stratis Health (Medicare QIO) ➔ 10 communities, 9 K to 200K residents ➔ Each team began with a needs assessment 26
MN Rural Palliative Care Initiative ➔ Interdisciplinary teams with members from hospital, home care, nursing home, public health, clinics, hospice, community ➔ Needs assessment ➔ 3 Learning Sessions and Outcomes Congress ➔ Small tests of change ➔ Based on NQF Preferred Practices 27
Application of NQF Preferred Practices ➔ #3 – PC education to health care professionals – 10 communities ➔ #1 – Use of interdisciplinary team – 5 communities ➔ #10 – Educating patients to make informed decisions – 4 communities ➔ #12 – Use of scales to measure symptoms – 4 communities 28
MN Rural Palliative Care Initiative ➔ Outcomes: – Increased knowledge of symptom management and goals of care discussions – 6/10 communities offering interdisciplinary palliative care services – Others developed/improved processes for ACP, common order sets to improve transitions, education to clinicians and community members 29
Quality Measures: Is it possible? ➔ Pilot study with 5 rural Minnesota communities to assess feasibility of collecting operational, clinical, satisfaction and utilization data ➔ Provided feedback on gaps in clinical assessment ➔ Demonstrated modest impact on utilization 30
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