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Service Delivery Innovation Profile

Comprehensive, Integrated Palliative Care Reduces Costs and Improves Satisfaction Among Patients and Their Families Within a Large Health System


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Snapshot

Summary

Fairview Health Services’ palliative care program offers palliative care in inpatient settings, clinics, and home care. The program is integrated into the care process to facilitate referrals and care coordination. Results of the program include a 50 percent reduction in primary symptoms and lower per-admission care costs.

Evidence Rating (What is this?)

Moderate: The evidence is based on a pre- and post-implementation comparison of symptom reduction among program participants, family satisfaction, and staff satisfaction. In addition, Fairview was included in a multisite study that compared the costs of care for patients receiving palliative care with those of a control group.
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Developing Organizations

Fairview Health Services
Minneapolis, MNend do

Use By Other Organizations

  • Fairview Health Services is one of eight Palliative Care Leadership Centers nationwide. The Palliative Care Leadership Centers offer 4 annual 2.5-day classes to hospital teams looking to replicate their palliative care model. Fairview specializes in “multi-hospital, community-based systems, small hospitals with limited resources, and use of the consult-team model.” Since February 2004, Fairview’s Palliative Care Leadership Center has hosted more than 150 teams, including more than 400 individuals in a range of disciplines from finance to chaplaincy.

Date First Implemented

2002

Problem Addressed

Palliative care programs incorporate a number of services for patients with serious illnesses, including symptom and pain management, supportive psychosocial and spiritual care, management of transitions between care settings, and support for medical decisionmaking.1 Although palliative care can improve quality of life and reduce care costs, fewer than half of all U.S. hospitals offer such care as an integral component of their services, leading to inadequate symptom control and unmet care needs for patients with advanced illness.
  • Variable access to high-quality, cost-effective palliative care: Today, approximately 45 percent of hospitals have palliative care programs, and the prevalence of these programs varies widely by state.2 
  • Lack of provider education is one problem: Many clinicians are not prepared to provide comprehensive palliative care because of a lack of education in training programs; until recently, medical schools and residency programs did not incorporate palliative care issues.3 Only 38 percent of physicians believe that they are qualified to provide palliative care, and, of those who provide palliative care, only 39 percent are certified in palliative medicine.4 The Centers for Medicare and Medicaid Services recognized hospice and palliative medicine as a medical subspecialty in October 2008, and 48 palliative medicine fellowship programs recently received accreditation.5

What They Did

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Description of the Innovative Activity

Fairview Health Services integrates palliative care into the health system’s existing organizational systems, with specialized palliative care teams offering comprehensive care in multiple settings. The program supports palliative care education and develops community partnerships to promote quality palliative care. Key elements of the program include the following:
  • Inpatient palliative care: Four of Fairview Health Services' seven hospitals have inpatient clinical programs. Palliative care services for inpatients include the following:
    • Hospital-wide palliative care consults: A provider can refer any hospitalized patient for a palliative care consult. A palliative care physician or palliative care advanced practice nurse responds to the consult request, which may include discussing goals of care with patients and families, providing appropriate symptom management, addressing other palliative care issues, and coordinating the intervention of other palliative care team members (e.g., spiritual care providers, clinical social workers, and integrative therapy providers) as necessary. The palliative care clinician works with the patient’s care team to integrate palliative care into the patient’s overall care plan. At the university hospital and a large community hospital, a palliative care team includes four disciplines (a physician, an advanced practice nurse, a clinical social worker, and a chaplain). At the other two hospitals, the teams are comprised of an advanced practice nurse, who collaborates with unit social workers and chaplains, and the patient’s physician to provide palliative care.
    • Palliative care progress note: The physician or the advanced practice nurse completes an initial and subsequent progress note, which is templated in the electronic medical record and reflects the domains of palliative care.
    • Pediatric palliative care: The program provides palliative care to seriously ill pediatric inpatients at the University of Minnesota Amplatz Children's Hospital. A palliative care physician is available to work with the pediatric clinical team to develop an individualized care plan that incorporates patient and family goals for symptom management, decisionmaking, and planning for care outside the hospital. In addition, specialists in poetry, art, and music therapy work with pediatric patients to facilitate other means of communication for children and reduce distress. The pediatric team and families work together to develop an end-of-life care plan.
  • Outpatient palliative care: In response to requests from physicians, patients, and family members, the palliative care program created the first outpatient palliative care clinic in Minnesota in 2005. The clinic provides palliative care consultation, support, and counseling for patients and families who would not otherwise have access to palliative care professionals. 
  • Perinatal palliative care: Information provided in August 2012 indicates that families facing a diagnosis of a possible or probable life-limiting diagnosis are offered perinatal palliative care at the University of Minnesota Amplatz Children's Hospital. The goal of this program is to provide family-centered care that provides a continuum of medical, psychosocial, and spiritual support through diagnosis, pregnancy, delivery, and death or transition to home. Parents participate in creating a plan consistent with their goals and wishes. Genetic counselors and perinatologists refer patients to the perinatal palliative care program.
  • Palliative home care: The palliative care program offers a palliative home-care program within Fairview’s home-care division for patients who are seriously ill but not yet ready for hospice care and for patients who have opted to continue treatment but have a limited prognosis. The palliative care home-care team and inpatient palliative care team communicate regularly to ensure continuity of care during care transitions.
  • Provider education: The palliative care program incorporates a number of strategies to enhance provider education and comfort with regard to providing palliative care. These strategies include the following:
    • Family conference initiative: Recognizing the need to improve communication among patients, families, and the health care team, social workers, chaplains, and selected nurses were offered education in family conference facilitation. The program uses an internally developed template to guide facilitators and physicians through the steps of conducting family meetings.
    • Fellowships and partnership with the academic health center: Beginning in 2008, the University of Minnesota Medical Center began offering a 12-month fellowship in palliative social work. In July of the same year, the palliative care program and the university’s Department of Family Medicine and Community Health began a palliative medicine fellowship. The fellowship includes two adult fellows and one pediatric fellow. The palliative care program partners with The University of Minnesota Academic Health Center to integrate palliative care into the educational curriculum. Students in many health care professional programs attend lectures and may complete a clinical rotation with the palliative care team. Information provided in July 2013 indicates that The University of Minnesota Palliative Care program received the Advanced Certification in Palliative Care from The Joint Commission in 2013.
    • Internal conferences: The palliative care program offers three conferences each year on palliative care topics, based on the National Consensus Guidelines for Quality Palliative Care and the National Quality Forum’s Preferred Practices for Palliative Care. These events are open to all staff, including volunteers, community parish nurses, and local clergy.
    • Palliative care program development: The Center to Advance Palliative Care has designated Fairview Health Services as one of eight Palliative Care Leadership Centers. In this capacity, Fairview hosts 4 annual 2.5-day conferences that educate attendees about how to develop and implement palliative care services in their own institutions. Fairview also offers onsite training and education for established palliative care teams.
  • Family support: The palliative care program offers a number of family support initiatives, including the following:
    • Symptom management and caregiver class: A registered nurse teaches families to assess and manage patient symptoms and addresses concerns, expectations, and strategies for managing care in the home. The class is held at the hospital; class duration is approximately 1 hour but varies depending on participant need.
    • Bereavement: Families who lose a loved one in the hospital receive a sympathy card followed by educational materials about grief and loss and an invitation to a memorial service for family members and staff held 6 to 9 months after the death. In addition, the palliative care program’s Web site includes information about grief and other practical resource information for bereaved families.
  • Best-practice dissemination: A system-wide Care Council meets regularly to allow representatives from multiple care settings to share ideas and best practices about palliative care. In addition, palliative care physicians and advanced practice nurses also meet periodically to ensure that they are standardizing care to deliver a consistent patient experience across all hospitals.
  • Community outreach: As part of the Minnesota Rural Palliative Care Initiative with Stratis Health, Fairview Health Services is working to develop palliative care programming in 24 rural communities. Together with other Minnesota health care systems, the palliative care program actively participates in the Honoring Choices Minnesota and Provider Orders for Life Sustaining Treatment program.

Context of the Innovation

Fairview Health Services is an integrated health care system with 7 hospitals, 37 primary care clinics, and 50 specialty clinics across Minnesota. Fairview created the palliative care program in response to an Institute for Healthcare Improvement (IHI) Improving Care at the End of Life initiative. The goal of this initiative, which was instituted in the late 1990s, was to promote care that could better meet the needs of patients and families at the end of life.

Did It Work?

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Results

The palliative care program has led to a 50-percent reduction in primary symptoms, a reduction in care costs, and improved family satisfaction.
  • Reduction of symptoms: Using the Modified Edmonton Symptom Assessment Scale, inpatient palliative care consult teams have found that patients report significantly fewer symptoms, including a 50-percent reduction in reported pain and decreased breathlessness and anxiety.
  • Cost savings: According to information provided in April 2009, an analysis of administrative data from eight hospitals (including Fairview Health Services) with established palliative care programs found that palliative care patients who were discharged alive had an adjusted net savings of $1,696 in direct costs per admission and $279 in direct costs per day (including significant savings in laboratory and intensive care unit costs) compared with usual care patients. The palliative care patients who died had an adjusted net savings of $4,908 in direct costs per admission and $374 in direct costs per day compared with usual care patients.2
  • Improved family satisfaction: Since the palliative care program’s implementation, family satisfaction surveys reveal improved satisfaction scores with regard to receiving consistent information about the patient’s condition, improved pain and symptom management, and adherence to patient preferences (as measured by the use of advance directives to guide patient care). Anecdotal reports are consistent with these results.
  • Positive feedback from staff: Clinicians have provided positive feedback with regard to the palliative care team’s involvement in patient care. As part of the program’s performance improvement plan, clinicians in selected units are surveyed to assess satisfaction with the service and identify areas for improvement.
  • National recognition: The palliative care program received the American Hospital Association’s Circle of Life Award in 2006.

Evidence Rating (What is this?)

Moderate: The evidence is based on a pre- and post-implementation comparison of symptom reduction among program participants, family satisfaction, and staff satisfaction. In addition, Fairview was included in a multisite study that compared the costs of care for patients receiving palliative care with those of a control group.

How They Did It

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Planning and Development Process

Institutions interested in developing palliative care programming can receive significant guidance, tools, and support from a number of institutions, including the Center to Advance Palliative Care and one of the eight Palliative Care Leadership Centers. Basic steps in Fairview’s own planning and development process included the following:
  • Creating an advisory group: Hospital leadership created a steering committee including membership from the organization’s board of directors to help plan the development of the palliative care service.
  • Obtaining outside guidance: The hospital used planning materials provided by the IHI initiative and the Center to Advance Palliative Care and talked to colleagues at hospitals that had already developed a palliative care service.
  • Incorporating palliative care into the health system: Hospital leadership emphasized the importance of palliative care by educating staff and surveying patients and families, leading to a system-wide culture change, and incorporating the palliative care program within the organizational structure.
  • Creating a palliative care progress note: The palliative care program created a standardized progress note for patient charts to reflect palliative care domains consistent with the national consensus guidelines for palliative care.
  • Ongoing analysis: The palliative care program’s quality committee identifies areas for improvement and reviews outcome data using a Plan-Do-Study-Act (PDSA) process. Quality information is reported to the entire team and hospital leadership. The program participates annually in the National Palliative Care Registry.

Resources Used and Skills Needed

  • Staffing: Staffing composition is different depending on the site. Across the system, the palliative care program includes eight physicians who are certified in hospice and palliative medicine and six advanced practice nurses. At the university and large community hospital, one social worker and a half-time chaplain are dedicated to the program.
  • Costs: The annual costs of the program are unavailable; salary costs comprise the vast majority of the palliative care program budget.
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Funding Sources

Robert Wood Johnson Foundation; Fairview Health System; New York Justice, Equality, Human Dignity and Tolerance Foundation; Coca Cola Company; Minnesota Twins; Minnesota Twins Wives Organization
Most insurance providers offer reimbursement for palliative care (including the symptom management patient education class); palliative care is billed as a consultation service in inpatient and clinic settings. However, insurance does not cover all palliative care program expenses. External funding through grants and philanthropy covers some nondirect (nonreimbursed) patient care costs, such as massage and art therapy. Employee donations provided through Fairview’s employee giving campaign have also helped fund the palliative care program’s activities.end fs

Tools and Other Resources

Information, tools, and guidelines are available from the following organizations:

Center to Advance Palliative Care: http://www.capc.org

National Consensus Project for Quality Palliative Care: http://www.nationalconsensusproject.org

National Consensus Project Guidelines for Quality Palliative Care: http://www.nationalconsensusproject.org/Guidelines_Download2.aspx

National Quality Forum’s Preferred Practices for Palliative and Hospice Care: http://www.rwjf.org/pr/product.jsp?id=18736

Palliative Care Leadership Center at Fairview Health System: http://www.capc.org/palliative-care-leadership-initiative/training-and-mentoring/fairview

Institute for Clinical Systems Improvement (palliative care guideline and order set): http://www.icsi.org

The Education in Palliative and End-of-Life Care Project: http://www.epec.net/

End-of-Life Nursing Education Consortium: http://www.aacn.nche.edu/ELNEC/

Adoption Considerations

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Getting Started with This Innovation

  • Estimate quality and financial impact of palliative care services: Many organizations are advocating for palliative care as a solution for quality and efficiency; palliative care supporters can reference these organizations and published studies when soliciting senior management support for program development.
  • Obtain staff buy-in: Begin developing a palliative care service by identifying clinicians who understand and are supportive of palliative care and by obtaining the support of organizational leadership.
  • Create an interdisciplinary development team: Palliative care can be offered in multiple settings and should be considered by practitioners in numerous medical disciplines. An interdisciplinary team can help tout the benefits of palliative care to clinicians in multiple professions and settings.
  • Promote early referral: Early referral to the palliative care consult team helps the patient and family set care goals that will inform subsequent care decisions.

Sustaining This Innovation

  • Be prepared for rapid growth: Experience shows that new programs receive more consultations than initially projected; volume quickly escalates as caregivers recognize the benefits of palliative care.
  • Track patient outcomes: Strong record keeping and data analysis allow the palliative care program to demonstrate its effectiveness and justify ongoing support from health system administration and from donors.

Use By Other Organizations

  • Fairview Health Services is one of eight Palliative Care Leadership Centers nationwide. The Palliative Care Leadership Centers offer 4 annual 2.5-day classes to hospital teams looking to replicate their palliative care model. Fairview specializes in “multi-hospital, community-based systems, small hospitals with limited resources, and use of the consult-team model.” Since February 2004, Fairview’s Palliative Care Leadership Center has hosted more than 150 teams, including more than 400 individuals in a range of disciplines from finance to chaplaincy.

Additional Considerations

  • Philanthropy can be an important part of the overall business plan, but dedicated personnel should be supported by system funding to ensure program stability.

More Information

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Contact the Innovator

Lyn Ceronsky, DNP, GNP-BC, CHPCA, FPCN
System Director, Palliative Care
F525 Riverside West
University of Minnesota Medical Center, Fairview
2450 Riverside Avenue
Minneapolis, MN 55454
(612) 672-6456
E-mail: lcerons1@fairview.org

Innovator Disclosures

Ms. Ceronsky has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Morrison RS, Penrod JD, Cassel JB, et al. Cost savings associated with US palliative care consultation programs. Arch Intern Med. 2008;168(16):1783-90. [PubMed]

More information on this program is available at:

Footnotes

1 National Quality Forum. National framework and preferred practices for palliative and hospice care. Available at: http://www.rwjf.org/pr/product.jsp?id=18736.
2 Center to Advance Palliative Care. A state-by-state report card on access to palliative care in our nation's hospitals. 2011. Available at: http://www.capc.org.
3 Smits HL, et al. Palliative care: an opportunity for medicare. Mount Sinai School of Medicine Institute for Medicare Practice. Available at: http://www.capc.org/support-from-capc/capc_publications/pc-medicare.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
4 Last Acts. Means to a better end: a report on dying in America today. Robert Wood Johnson Foundation, November 2002.
5 Interview with Lyn Ceronsky, February 23, 2009.
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: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: September 11, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: July 29, 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.