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

Problem Addressed

• Little access to high-quality, cost-effective palliative care: Today, approximately one in five hospitals have palliative care programs, but the prevalence of these programs varies widely by state.² 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.³ 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, and the researchers further determined that patterns of referral to palliative care services were not well-defined.⁴
• Lack of provider education is one problem: Many clinicians do not provide good palliative care because of a lack of education about palliative care issues; until recently, medical schools and residency programs did not incorporate palliative care issues.⁵ 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.⁶ 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.⁷ 

Description of the Innovative Activity

• Inpatient palliative care: Four of Fairview Health Services’s seven hospitals have inpatient clinical programs. Palliative care services for inpatients include the following:
  • Hospital-wide palliative care consults: A physician can refer any hospitalized patient for a palliative care consult. Information provided in April 2009 indicates that a palliative care physician or palliative care advanced practice nurse performs the consult, discussing goals of care with patients and families, providing appropriate symptom management, addressing other palliative care issues, and suggesting the intervention of other palliative care team members (e.g., spiritual care providers, social workers, and providers of music and art therapy) as necessary. The palliative care physician works with the patient’s care team to integrate palliative care into the patient’s overall care plan. At the university hospital, a palliative care team includes four disciplines (a physician, an advanced practice nurse, a social worker, and a chaplain); at the other three hospitals, the teams are centered around an advanced practice nurse, who pulls in unit social workers and chaplains and the patient’s physician to provide palliative care.
  • Palliative care progress note: Information provided in April 2009 indicates that the physician or the advanced practice nurse completes an initial and subsequent progress note, standardized and templated in the electronic medical record, that tracks approximately 12 symptoms and discussions about goals of care. Clinicians complete the note daily or as determined by patient need.
  • Palliative care kits: Inpatient units have access to palliative care kits that contain massage cream for hand massage, nightlights, books for children explaining death, and materials to educate families about typical changes that occur (e.g., emotional withdrawal) as the patient nears death.
  • Pediatric palliative care: The program provides palliative care to seriously ill pediatric inpatients at the University of Minnesota Children's Hospital. A palliative care physician works with the patient’s 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. The palliative care physician and the patient’s social worker, chaplain, primary nurse, primary physician, and a child/family life representative hold scheduled rounds twice monthly to update the palliative care plan. In addition, specialists in poetry, art, and music therapy work with pediatric patients to reduce suffering.
• Outpatient palliative care: In response to demand from physicians, patients, and family members, the palliative care program created the first outpatient palliative care clinic in Minnesota. The clinic provides palliative care consultation, support, and grief counseling for patients and families who would not otherwise have access to palliative care professionals. Information provided in April 2009 indicates that genetic counselors and other perinatology clinicians also refer patients to the pediatric palliative care team, which offers perinatal palliative care consultations on an outpatient basis with families whose unborn baby will die before or shortly after birth; one outcome of the consultation is the development of a birth plan that reflects the family’s goals and wishes, including prevention of aggressive treatment interventions if these are not desired.
• Palliative home care: The palliative care program offers a 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 curative medicine but have a poor prognosis. The palliative care home care team communicates regularly with the inpatient palliative care team 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.
  • Partnership with academic health center: 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, including the medical school, the nursing school, and programs related to spiritual care and social work can attend lectures and complete a clinical rotation with the palliative care team. The palliative care program and the University of Minnesota Department of Family Medicine and Community Health began a palliative medicine fellowship in July 2008 (accredited in 2009), and a social work fellowship in palliative care began in September 2008.
  • 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, parish nurses, and local clergy. Staff members who attend receive continuing education units.
  • Leadership conferences for other medical centers: The Center to Advance Palliative Care has designated Fairview Health Services as one of nine Palliative Care Leadership Centers. In this capacity, Fairview hosts four annual 2.5-day conferences that educate attendees about how to develop and implement palliative care services in their own institutions. Fairview also offers on-site 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.
  • Children’s programs: A pediatric palliative care coordinator leads programs that support children in saying goodbye or expressing their feelings. Programs may incorporate art, music, and other modalities that can help children deal with grief. Targeted groups include children with advanced illness, children of adult patients with advanced illness, and siblings of children with advanced illness.
  • 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, Fairview Health Services is working to develop palliative care programming in 10 rural communities.

References/Related Articles

• http://www.fairview.org/tlc/
• http://www.rwjf.org/files/publications/other/meansbetterend.pdf

Contact the Innovator

Results

• 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 to 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, relief of the patient’s pain; symptom management, and adherence to patient preferences (as measured by the use of advance directives to guide patient care). Anecdotal reports also reflect improved family satisfaction.
• Positive anecdotal feedback from staff: Clinicians have provided positive feedback with regard to the palliative care team’s involvement in patient care. In particular, nurses welcome the palliative care team’s involvement, which allows for a significant increase in support for the patient and family (especially with regard to decisionmaking and pain relief).
• National recognition: The palliative care program received the American Hospital Association’s Circle of Life Award in 2006.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Creating an advisory group: Hospital leadership created an advisory group 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 concept of palliative care into the organizational structure.
• Creating a palliative care progress note: The palliative care program created a standardized progress note for patient charts that tracks 10 to 12 symptoms and goals of care that are consistent with the national consensus guidelines for palliative care.
• Ongoing analysis: Data collected from the standardized progress notes is analyzed as a part of the evaluation to measure the impact of the program on key outcome measures.

Resources Used and Skills Needed

• Staffing: Staffing composition is different depending upon 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 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.

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

Tools and Other Resources

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 allows the palliative care program to demonstrate its effectiveness and justify ongoing support from health system administration and from donors.

Additional Considerations and Lessons

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

Use By Other Organizations

• Fairview Health Services is one of nine Palliative Care Leadership Centers nationwide. The Palliative Care Leadership Centers offer four 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 100 teams including more than 400 individuals in a range of disciplines from finance to chaplaincy.