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Service Delivery Innovation Profile

Palliative Care Nurses in Primary Care Clinics Reduce Hospital Admissions, Increase Use of Hospice and Home Care for Patients Nearing End of Life


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Snapshot

Summary

A palliative care partnership between a hospice organization and a multilocation multispecialty group practice places palliative care nurses in primary care clinics to monitor frail, chronically ill elderly patients' medical and social care needs, coordinate community services, and discuss end-of-life issues. An evaluation revealed that 53 percent of patients who received palliative care were not admitted to the hospital 60 days before death, compared with just 28 percent of patients who did not receive palliative care. In addition to reducing end-of-life admissions, the program has increased use of hospice and home care services for chronically ill elderly patients, thus improving end-of-life care for patients and their families.

Evidence Rating (What is this?)

Moderate: The evidence consists of a small trial of 140 patients over age 65 who passed away between August 2004 and January 2006 that compared key outcomes from those receiving palliative care services to those not receiving the services.
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Developing Organizations

Everett Clinic; Providence Hospice and Home Care of Snohomish County
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Date First Implemented

2004
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Patient Population

Age > Aged adult (80 + years); Vulnerable Populations > Frail elderly; Age > Senior adult (65-79 years); Vulnerable Populations > Terminally illend pp

Problem Addressed

Although palliative care can improve dying patients' quality of life and reduce costs by facilitating care in a nonhospital setting, very few providers offer such care as an integral component of their service for the elderly. Instead, patients nearing the end of life tend to receive expensive, acute care that is designed to prolong life, even though many of these patients and their families may prefer palliative care.
  • Growing need for palliative care services: By 2030, the number of Americans aged 65 and older will more than double to 71 million, meaning that this age group will make up roughly 20 percent of the U.S. population.1
  • High costs of care for dying patients: Almost one-third (30 percent) of the total Medicare budget is spent in the last year of life; of the total amount spent in the last year of life, nearly 40 percent is spent in the last 30 days.2
  • Little access to high-quality, cost-effective palliative care: Palliative care services provide a number of benefits to chronically ill, end-of-life patients, including reduced pain; improved quality of life; and a reduction in emergency department (ED) visits, hospitalizations, and health care costs.3 Hospice care and advance directives can save between 25 and 40 percent of health care costs during the last month of life.4 Palliative care services, however, are notably uncommon. For example, a study involving a random sample of California hospitals found that only 17 percent had a palliative care consult service, and only 6 percent had an inpatient palliative care unit.5 The use of a palliative care specialist is even more rare in outpatient settings. Even older, terminally ill patients often lack access to palliative care services. One study found that older patients were less likely to receive palliative care than younger patients and that caregiver age was an important predictor of palliative care use as patients aged.6 A separate study found that only 34 percent of inpatients who died of cancer at the M.D. Anderson Cancer Center in 2003 and 2004 had access to palliative care services, despite the fact that palliative care services resulted in a lower cost of care; the researchers further determined that patterns of referral to palliative care services were not well defined.7

What They Did

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Description of the Innovative Activity

Providence Hospice and Home Care and the Everett Clinic partnered to offer a clinic-based palliative care program dedicated to improving the quality and cost-effectiveness of care for seniors, and to addressing end-of-life care issues. Palliative care nurses are located at 7 of the Everett Clinic's 11 locations, working with a total of 18 physicians and approximately 700 patients. The goal of the palliative care program is to prevent unnecessary hospital admissions and ED visits, ensure appropriate followup care in the physician's office, and coordinate community and end-of-life services. The central feature of the program is the placement in a primary care clinic of a palliative care nurse who develops a relationship with the physician and clinic staff and facilitates timely care and service referrals for patients in need, thereby preventing a cycle of rehospitalizations when hospice or home care would be more appropriate. Elements of the initiative are as follows:
  • Patient referrals to no-cost, voluntary program: Patients can be referred to this free, voluntary program by physicians and other caregivers. The typical patient referred is an individual age 75 or older who has multiple comorbidities, such as coronary artery disease, congestive heart failure, and dementia. Most referrals come from physicians or a hospital transition coach, who refers inpatients who are vulnerable (as evidenced by multiple hospital stays). Enrollment criteria are designed to identify patients who may not yet qualify for hospice care, but who could benefit from palliative care. Physicians are instructed to consider referring patients who they believe are likely to die within the next 1 or 2 years. Physicians also are encouraged to consider referrals for elderly patients who are declining or frail and have required multiple hospitalizations. A physician may also refer patients who have difficulty accessing health care, particularly when the physician feels overwhelmed in managing both the medical and the social care of the patient. Palliative care nurses, who sit in a central location within the practice, sometimes ask physicians about the appropriateness of the program for certain frail, elderly patients they observe.
  • Program services provided by onsite nurse: Six full-time palliative care nurses and two part-time program assistants are shared among the seven clinics. During office visits, physicians often invite the nurse to speak with potential candidates and their family members/caregivers (when present) about the program. In some cases, this conversation is held over the telephone. In either case, the main purpose is to explain the program and gauge the patient's interest in it. Those who choose to enroll receive the following services from the nurse:
    • Initial enrollment: Interested individuals receive more information about the program, including contact telephone numbers and information about the nationally based Lifeline program for seniors who live alone. Patients receive and fill out the Physician's Order for Life-Sustaining Treatment form that designates desired care at the end of life.
    • Ongoing care management: The nurse provides family counseling on current care needs and end-of-life issues; performs periodic telephone assessments of medical issues, including pain management, urinary tract infections, and fall risks; conducts (as needed) home visits to assess the patient directly; and coordinates community and social services, including palliative care services. Nurses provide referrals to all hospice agencies within the community. When the nurse sees a patient who seems like a good candidate for hospice or home care, the nurse contacts the family, coordinates the referral, and becomes the contact person for the agency.
    • Provision of care as part of the care team: The palliative care nurse is a full-fledged member of the patient's care team. As appropriate, the nurse makes recommendations to the physician about needed treatments or services. When patients call to make an appointment or reorder medications, the call is filtered through the palliative care nurse, and the nurse participates in the patient's office visits.
    • Proactive outreach: The nurse calls each patient once a month to check on his or her health status and needs.
  • Support for the nurses: A part-time program assistant works with each nurse; program assistant duties include entering patient data into a database for evaluation purposes, assisting with proactive patient telephone calls, and directing incoming calls to the palliative care nurse. Nurses also attend regular staff meetings to discuss the program, solicit feedback, and address concerns. In managing patients, the palliative care nurse has access to the clinic's electronic medical record (EMR) to assess patient health records, book appointments with clinic physicians, and send electronic notifications about patient care plans to clinic physicians and nurses. Thanks to the EMR, each nurse can manage approximately 250 patients (compared with 175 patients per nurse at the Franciscan Health System program that served as the model for this initiative).
  • Program evaluation: In addition to the database, clinic staff are surveyed annually to obtain feedback about the program; patient surveys have been completed and are being compiled.
    • Clinic survey questions include the following:
      • Is the program beneficial to my patients?
      • Are program staff easily accessible when needed?
      • Do staff address patient needs in a timely manner?
      • Is this program an important resource for me?
      • Has this program helped reduce my workload for selected patients?
    • Patient survey questions include the following:
      • How satisfied are you with your ability to contact palliative care staff?
      • How satisfied are you with the communication/coordination between palliative care and your physician?
      • How satisfied are you with palliative care's help with pain control?
      • How satisfied are you with help of palliative care in coordinating specific care needs, for example: symptoms like shortness of breath, equipment, wound care?

Context of the Innovation

Providence Hospice and Home Care of Snohomish County is a nonprofit organization with a 30-year history of providing compassionate, quality care to patients at the end of life. Through its experience in the community, Providence Hospice and Home Care recognized that many patients were either not appropriate for hospice services or had been discharged from hospice or home care as stable, but still needed supportive programs. In addition, although palliative care and end-of-life services were generally available for patients who were either very poor (and covered by Medicaid) or wealthy, Providence staff saw many other patients and families fall through the cracks without awareness of or access to palliative care and other community support services.

Providence researched potential programs and uncovered a palliative care program developed in the early 1990s by the Franciscan Health System in Tacoma, WA, called Improving Care Through the End of Life; the Franciscan Health System was offering the program to other agencies throughout the community. The Director of Hospice at Providence obtained the rights to adopt the program, re-created the forms to reflect the Providence brand, and began contacting clinics in the community to determine interest in allowing Providence to offer the program. The Everett Clinic, a multispecialty group practice with more than 270 physicians and 1,450 staff serving 250,000 patients annually at 11 sites, agreed to participate.

Did It Work?

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Results

The palliative care program has reduced the utilization of expensive acute care by substituting the provision of high-quality home care and hospice services, leading to improved quality of end-of-life care.
  • Significantly fewer hospitalizations: The program studied 140 patients over age 65 who passed away between August 2004 and January 2006 and found that 53 percent of those who received palliative care had not been admitted to the hospital 60 days before death, compared with just 28 percent of patients who did not receive palliative care. In addition, patients receiving palliative care who were admitted to the hospital had an average of 1.9 hospital admissions, compared with 2.4 admissions for patients not receiving palliative care.
  • Increased use of high-quality end-of-life services: In the evaluation of 140 patients, the palliative care program increased the use of hospice services, with median hospice length of stay of 47 days for patients receiving palliative care services, compared with 6 days for patients not receiving these services. In 2007, 119 referrals to home care agencies and 129 referrals to hospice agencies were made; based on past experience, program coordinators estimated that approximately 50 percent of these referrals would not have been made in the absence of the program. Information provided in January 2014 indicates that as of year-end 2013, the program had made 124 referrals to home care and 320 referrals to hospice care; 71 percent of all program patients died on hospice care, versus the 2010 national average of 41 percent, and the median hospice length of stay for program participants was 40 days, compared with 14 days for patients of a hospice agency (without program).
  • Cost-effectiveness: Although no hard data are available, the program promotes cost-effectiveness by reducing the use of expensive inpatient and ED care, replacing it with less expensive hospice and home care. This allows the Everett Clinic to demonstrate to payers that it is a cost-effective organization that serves patient needs.
  • High staff satisfaction: Annual staff satisfaction surveys completed at two of the three initial clinic locations received ratings of 4 out of 5 for registered nurse respondents and 5 out of 5 for medical doctor respondents. All survey comment feedback has been positive.
  • High patient/family satisfaction: Patients and families responding to a 2011 mailed survey recorded a satisfaction rating of 4.8 out of 5 points.

Evidence Rating (What is this?)

Moderate: The evidence consists of a small trial of 140 patients over age 65 who passed away between August 2004 and January 2006 that compared key outcomes from those receiving palliative care services to those not receiving the services.

How They Did It

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Planning and Development Process

Key steps in the planning and development process include the following:

  • Senior administration buy-in: Senior administrators at Providence Hospice and Home Care and the Everett Clinic were introduced to the program and agreed to move forward with it.
  • Initial site: Providence placed the first palliative care nurse in the Everett Clinic Main Campus location in August 2004. The site was selected based on the clinic's focus on primary care and its high percentage of Medicare patients.
  • Physician champion: The nurse met with the physicians at the site and asked for someone to serve as a champion for the program. The physician who offered his services had the largest panel of elderly patients. As other physicians observed how the program worked, they began making more referrals to it.
  • Designated space: Initially, there was no designated space for the palliative care nurse, so she worked with a laptop computer in any available space. The first few months were a trial period to see if the program would be beneficial; however, it quickly became clear to the physicians that the program provided a great benefit to these frail patients, and a designated space was found for the nurse.
  • Program expansion: Information provided in January 2014 indicates that the program has been expanded to seven clinics and now cares for approximately 1,330 patients. New clinic sites include Providence Regional Cancer Partnership as well as additional Everett Clinic sites and the Providence Physicians Group. Clinic sites were selected based on their primary care focus and high percentage of Medicare patients.

Resources Used and Skills Needed

  • Staffing: Information provided in January 2014 indicates that the program uses six palliative care nurses who are employees of Providence Hospice and Home Care; Providence now employs three program assistants and Everett Clinic employs one support staff person (all of whom are shared among the seven clinic sites).
  • Space and equipment: Everett Clinic provides space for the palliative care nurse and allows use of its EMR.
  • Costs: The 2008 budget program for salary and benefits was $330,000, which included the staff for the three existing clinics and planned staff for a registered nurse to support two additional clinics. This number does not include the one support staff person funded by Everett Clinic, and has not been updated to account for additional clinic expansion since 2008. The services are not reimbursed by Medicare.
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Funding Sources

Providence Hospice and Home Care of Snohomish County; Everett Clinic
Funding for the program comes from Providence Hospice and Home Care and the Everett Clinic.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Identify a physician champion: A physician champion, ideally someone who cares for many elderly patients and has the respect of his or her peers, is critical to program success.
  • Obtain clinician buy-in: Set aside a time for a meeting with the palliative care nurse and the clinic physicians to provide a program orientation and ensure physician understanding and support. Emphasize that the palliative care nurse can provide enhanced quality of care for patients while alleviating some of the medical and social care burden on physicians and staff.
  • Integrate the palliative care nurse into the practice: Locate the palliative care nurse onsite in the clinic so that he or she can see patients in the office, develop relationships with physicians and nurses in the practice, and discuss and implement real-time solutions. Fully integrate the palliative care nurse in the practice; for example, the nurse should participate in team meetings.
  • Address financial concerns: Emphasize quality of care when reimbursement concerns arise. Create a business case for the program that highlights, as relevant, the fees generated by increased use of and length of stay in hospice care and utilization of home care services, or the cost savings associated with reduced ED and inpatient care use.

Sustaining This Innovation

  • Solicit ongoing feedback: Solicit feedback from clinicians to ensure their continued support and appropriate work processes.
  • Take care in introducing the program to patients: The palliative care nurses do not describe themselves as hospice nurses to patients and families because some individuals might find this to be disturbing. Rather, they introduce the program as focusing on palliative care, with the goal of better coordinating care and improving the end-of-life experience.

More Information

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Contact the Innovator

Steven Jacobson, MD
Associate Medical Director - Strategic Health Services
3901 Hoyt Ave
Everett, WA 98201
(360) 563-8600
E-mail: sjacobson@everettclinic.com

Velda Filzen, RN, BSN, CHPN
Clinical Coordinator - Partners in Palliative Care
Internal Medicine Department - Founders Bldg.
3901 Hoyt Ave
Everett, WA 98201
Phone: (425) 257-1492
Fax: (425) 259-1154
E-mail: vfilzen@everettclinic.com

Innovator Disclosures

Ms. Filzen reported having no financial interests or business/professional affiliations relevant to the work described in this profile. Dr. Jacobson has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

Recognition

In 2010, the Everett Clinic and Providence Hospice and Home Care received the American Hospital Association (AHA) Circle of Life Award for their clinic-based palliative care partnership in Snohomish county. The Circle of Life Awards honor innovative programs in palliative and end-of-life care; more information is available at http://www.aha.org/about/awards/col/awardees.shtml.

References/Related Articles

Trisolini M, Pope G, Kautter J, et al. Medicare physician group practices: innovations in quality and efficiency. The Commonwealth Fund. 2006 Dec;8-10. Available at: http://www.commonwealthfund.org/publications/fund-reports/2006/dec
/medicare-physician-group-practices--innovations-in-quality-and-efficiency
.

Footnotes

1 Centers for Disease Control and Prevention and The Merck Company Foundation. The State of Aging and Health in America 2007. Whitehouse Station, NJ: The Merck Company Foundation; 2007. Available at: http://www.cdc.gov/aging/pdf/saha_2007.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
2 Lubitz JD, Riley GF. Trends in Medicare payments in the last year of life. N Engl J Med. 1993;328(15):1092-6. [PubMed]
3 Morrison RS. Palliative care outcomes research: the next steps. J Palliat Med. 2005;8(1):13-6. [PubMed] Also available at: http://www.liebertonline.com/doi/abs/10.1089/jpm.2005.8.13.
4 Emanuel EJ. Cost savings at the end of life. What do the data show? JAMA. 1996;275(24):1907-14. [PubMed]
5 Pantilat SZ, Billings JA. Prevalence and structure of palliative care services in California hospitals. Arch Intern Med. 2003;163(9):1084-8. [PubMed]
6 Grande GE, Farquhar MC, Barclay SI, et al. The influence of patient and carer age in access to palliative care services. Age Ageing. 2006;35(3):267-73. [PubMed]
7 Fadul N, Elsayem A, Palmer JL, et al. Predictors of access to palliative care services among patients who died at a Comprehensive Cancer Center. J Palliat Med. 2007;10(5):1146-52. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: December 18, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 13, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: December 21, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.