Best Practices: Right Care, Right Time
Features
Written by Matt Bolch   
Thursday, 01 May 2008
Best Practices: Right Care, Right Time - Health Executive - RedCoat Publishing
Palliative care programs are gaining momentum as a way to help hospitals deal with patients suffering complex conditions.
Working in an environment where 90% of your patients die can be trying for even the most experienced medical staffers. That’s why New York-based Calvary Hospital chooses its workers carefully, preferring to leave a position open than to make a wrong hire.

Dr. Robert Brescia, senior vice president and executive medical director, emphasizes that the 200-bed hospital facility in the Bronx and 25-bed satellite center at Lutheran Medical Center in Brooklyn is not a training facility but a hospital dedicated to caring and compassion for adult, advanced cancer patients.

Calvary has been called the nation’s only acute care specialty hospital devoted to providing palliative care to cancer patients, and it routinely places in the 99th percentile in patient satisfaction, according to Press Ganey.

“Every family member is a patient, and sometimes 90% of our energy and efforts are devoted to the care of the family,” said Brescia. “Our hospital is set up by the way people suffer to treat their physical pain, as well as address their emotional, mental, and spiritual needs.”

Increasing referrals
An increasing number of hospitals are recognizing the value of palliative care programs, which address the complex needs of patients at any time during an illness. Although palliative care programs often overlap with hospice, the latter is designed for terminally ill patients with six months or fewer to live and after curative therapies have been discontinued.

According to the Center to Advance Palliative Care (CAPC), seven in 10 hospitals with 250 or more beds have a palliative care program, a figure that drops to 55% among hospitals with 100 to 249 beds. Between 2000 and 2006, the number of hospitals with such a program jumped from 632 to more than 1,300, according to an annual survey from the American Hospital Association.

“Palliative care assesses the needs of patients with complex conditions, adopts a plan of action, and delivers the right care to the right patient at the right time,” said Dr. Diane Meier, director of CAPC and the Hertzberg Palliative Care Institute at the Mount Sinai School of Medicine.

Mount Sinai began its palliative care program in 1997, anticipating about 50 referrals in the first year. That first-year figure turned out to be 250, and the hospital now has about 1,000 new palliative patients each year.

Providing palliative care services is not a profit center for hospitals. The goal is to be revenue neutral, paying for the program through cost avoidance associated with long hospital stays and better patient throughput. The family of a patient on a ventilator, for example, may need time to determine the best care option, but the patient doesn’t have to take up an ICU bed to receive an appropriate level of care. Gains also come through higher patient satisfaction scores and higher employee morale.

Some hospitals develop their own criteria for who might benefit from palliative care services; others rely on physician referrals. Older physicians are not as likely to make referrals because palliative care was a relatively unknown concept a few decades ago. Today, Meier said that 80% of medical schools have palliative care programs, which has done a great deal to increase their prevalence in hospitals nationwide.

Palliative care programs have gained significant recognition recently. The American Board of Medical Specialties recently recognized hospice and palliative medicine as an official subspecialty, and the National Quality Forum has released best practice guidelines surrounding palliative care.

CAPC has a number of palliative care resources on its Web site (www.capc.org), including an impact calculator to help hospitals estimate how such a program can benefit the organization: (www.capc.org/impact_calculator_basic/).

Showing value
Dr. David Steinhorn was instrumental in establishing a pediatric palliative care program in the mid-1990s at what’s now The Women and Children’s Hospital of Buffalo before starting a similar program at Children’s Memorial Hospital in Chicago. Steinhorn is medical director of The Bridges Program, which provides palliative and end of life care, and a pediatrics professor at Northwestern University’s Feinberg School of Medicine.

“Palliative care should be a central, pivotal part of a tertiary care center,” said Steinhorn. “You can’t do heroic medicine without palliative care help.”

The program at Children’s features a palliative care team that consists of three physicians in rotation who are joined by a full-time advanced practice nurse and social worker/manager, a chaplain and child/life worker devoted to the program half time, and adjunct workers brought in on an ad hoc basis to manage symptoms and pain and give advice.

“Any child with a clinical condition that presents a significant barrier to reaching adulthood should get a palliative care consult,” said Steinhorn, who adds that the benefits to the patient and hospital are three-fold.

A hospital should be setting the standard for community care, and a palliative care program is a critical component, he said.

There’s also value in keeping patients out of the hospital. Studies in Washington state and New York show the cost neutrality of palliative care programs, Steinhorn said, but a study of the program in Buffalo showed a 90% reduction in spending between hospital-based care and home-based palliative care to manage symptoms.

Finally, Steinhorn said there’s a moral aspect to palliative care. “A healthcare system should be providing compassion and caring, but without a palliative care program, it’s difficult to provide holistic care to a patient and family possibly facing death in six to nine months.”

Although CAPC maintains that hospitals can start out with a palliative care team and later shift to a dedicated unit, Brescia from Calvary Hospital believes that doctors, nurses, and social workers who work solely in palliative care are what patients and their families need most.

“Boards and the leadership of hospitals first have to believe in this,” Brescia said. “Once there is the belief that the institution can bring dignity to every patient, there are special individuals to hire and an isolated unit to set up. If the unit is not separate, there will be different levels of care depending on who’s working, and that doesn’t benefit the patient.”

Matt Bolch, This e-mail address is being protected from spam bots, you need JavaScript enabled to view it , is a freelance writer based in Atlanta.
 
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