JOURNAL OF PALLIATIVE MEDICINE Volume 18, Number 3, 2015 ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2015.1014
Notes from the Editor
Improving Care during a Time of Crisis: The Evolving Role of Specialty Palliative Care Teams David E. Weissman, MD, FAAHPM, Founding Editor
M
uch of my work over the past 10 years has focused on supporting the growth and sustainability of hospital palliative care teams. In that capacity I’ve had the pleasure to meet with dozens of teams and learn of their successes and struggles. The good news is that over the past 5 years there has been an unprecedented rise in the demand for inpatient and outpatient clinical services coming from both clinicians and administrators. The downside is that most teams I meet with are struggling, overwhelmed by the workload demands. I find that teams have staff with great clinical knowledge and skills, but often lack staff with knowledge and experience in navigating these stressors, such as strategic and business planning and human resource management. Faced with growing clinical demands, teams follow a predictable path, whereby they increase their clinical workload at the expense of data collection, education, quality improvement, and most importantly, team health. An early warning sign is when teams abandon teaching opportunities and provision of interdisciplinary care; increasingly I visit teams where each staff member has their own panel of patients with no crossdisciplinary engagement, violating a foundational precept of palliative care. As teams struggle to meet new demands, they inevitably ask for additional staff, often met with administrative indifference, in part due to the teams’ inability to adequately make the case for more resources in a manner that aligns with health system priorities, leading to staff frustration and further deterioration in team function. In prior editorials I have written about the dangers of being a team martyr and how teams can embrace the new reality of increasing clinical demand by starting to shift some of their work to support increased generalist-level palliative care training and system-change efforts.1,2 Although I find some teams working to embrace these ideas, far too many are trapped in an unproductive cycle of feeling overwhelmed and underappreciated. In this editorial I outline some concrete steps teams can take to move forward.
1. Self Care/Team Care
A principle of palliative care is that before you can help a patient establish goals, physical symptoms need to be well managed. Similarly, before teams can move forward they need to openly address issues of team health and correct dysfunctional team behaviors, including martyrdom. Since palliative care specialist clinicians are a scare resource, all teams need a proactive strategy for both prophylactic and interventional team health. At a minimum, teams should complete a self-assessment of team function and develop a
plan for consistent activities to both assess and promote improvements in team health.3 2. Workload Assessment
Teams are buffeted by increasing demands for clinical services and by new administrative imperatives to expand services to new patient populations and new care venues. Most teams approach these requests as if they have no voice in decision making, not wanting to offend administrators or colleagues who request their services. Thus, a key step is for teams to step back, take a deep breath, and gain some control over their own destiny. A few key questions can begin the process:
Are there opportunities to change daily work processes to increase efficiency without abandoning core palliative care principles? Are there patients that no longer need team follow-up in which the team can ‘‘sign off’’? Are there frequent consultations that are outside staff knowledge/skills? Are there frequent consultations that are outside the program scope of practice? What percentage of consultations represent generalistlevel palliative care, as compared to true specialistlevel consultations? Can some of the generalist-level requests be managed by curbside advice, rather than a full consultation?
Once these questions are discussed and teams recognize the gap between current and desired practice, they need to give themselves permission to set boundaries around their services and set program goals that realistically match their resources. Some will argue that setting limits around consultation practice has the potential to anger referring clinicians, leading to a drop in consultation volume. In the past, when we often struggled to prove our value, this was a reasonable concern. But such is not the case anymore for programs that are growing beyond their resources. Setting limits is a natural evolutionary step in program development that reinforces the notion that we are a true specialty, rather than a ‘‘feel-good’’ service for any and all needs of sick patients. 3. Scope of Services
Most teams, at the time of program inception, develop a marketing message including indications for referral. But seldom do I see teams make changes in how they market themselves as their program grows. The most common issues I see
204
NOTES FROM THE EDITOR
teams struggle with as they get busier are how to handle requests for chronic nonmalignant pain management, substance abuse assessment, hospice informational visits, and requests to manage time-intensive procedures such as a planned ventilator withdrawal. Each team needs to decide the relative value of their time and expertise in handling these and similar requests, in comparison to the more traditional palliative care specialty consultations for symptom management, conflict resolution, goal setting, and discharge planning.4 To help teams realign their resources with current clinical demands, I encourage all teams to develop a Scope of Services document, reassessed annually, that outlines four domains: indications for referral, diagnoses suitable for referral, consultation management options, and team availability (see Fig. 1). 4. Service Standards
Service standards define how a team operationalizes their day-to-day work. This is vital information both for the team itself, especially when new staff are added, and for referring clinicians. Establishing a list of service standards is an excellent team building exercise that, like the Scope of Services, should be reviewed annually. Key domains of service standards include daily work process, interactions with referring clinicians, and other components specifying the whodoes-what-when of the interdisciplinary team (see Fig. 2). 5. Strategic Planning
Strategic planning is a process to define a program’s goals and make decisions on how to achieve those goals based on available resources, or in the words of Yoggi Berra, ‘‘If you don’t know where you are going, you might not get there.’’5 Strategic planning for palliative care teams involves an analysis of current work, assessment of opportunities for new services, appraisal of staffing resources necessary to expand into new programmatic areas, and making a plan to operationalize the steps necessary to achieve the desired goals (see Fig. 3). Strategic planning involves the palliative care team and key stakeholders, including health system administrators, key clinicians, and others necessary to get the big picture of how palliative care services can best impact the health care enterprise. Program leaders who are unsure of how to go about a strategic planning process can usually find someone from hospital administration to help guide the process. Summary
The five elements outlined here should not be thought of as linear steps to be completed in the order of presentation, but rather a cycle of work processes. A natural starting point is to first work on team health and complete a strategic planning process and workload assessment, with subsequent changes made to the Scope of Practice and Service Standards. As teams work through the five elements they should also ponder their potential to impact the local health care culture beyond specialist consultations. I find that many teams are fixated on increasing their consultation volume as the key measure of value and impact. Indeed volume is one measure of how well the palliative care team is viewed by referring clinicians. But focusing on consultation volume alone limits the vision of
205
what palliative care, as a force for culture and practice change, can achieve. Forward-thinking hospitals and health systems are starting to recognize that palliative care services represent more than an end-of-life service line; palliative care concepts that are widely integrated can have positive impacts that ripple through all aspects of the institution and improve outcome metrics that administrators care about. If I were a hospital administrator, I would want the specialty team to spend no more than 50% of their time seeing consultations, and the other 50% working on elements of systems/culture change with a goal of improving the care of all patients with unmet palliative care needs, not just those fortunate enough to be referred for consultation.6 Furthermore, I would change how palliative care clinicians are evaluated for productivity, from a system based on clinical patient volume and billing to one focused on culture change that brings about a true system of patient-centered care. Systems change work includes educating our colleagues in generalist-level palliative care, developing screening pathways to identify patients with unmet needs, patient/family and community education, quality improvement processes, and establishment of standards, tools, and metrics to improve and measure patient-centered care.2,6 Granted, most palliative care clinicians today view themselves as clinicians first, rather than as agents for system change or education. And yet, when I meet with teams, it is the lack of culture change (e.g., ‘‘Why did the emergency physician admit this dying patient to the intensive care unit’’ or ‘‘Why did this patient suffer for three days with severe pain before they called us?’’) that is an ever-present source of team distress. In the early days of our specialty, the vision of palliative care was that it could positively impact the cure at all costs culture of health care and help shift care from clinician-centered to patient-centered. Starting a specialty consultation service was viewed as one of many important building blocks in realizing this goal. To fully realize that early vision, specialist teams can continue their good clinical work, but also seek out opportunities to change the larger culture of care through systems change and education. As a first step, teams need to remind themselves that they have control over how they meet the increasing demands for their time and services through self and team care, defining the boundaries of their services, and strategic planning. References
1. Weissman DE: Palliative care martyrs. J Palliat Med 2011; 14:1279–1280. 2. Weissman DE: Next gen palliative care. J Palliat Med 2012; 15:2–4. 3. Altillio T, Dahlin C, Remke SS, et al.: Strategies for maximizing the health/function of palliative care teams. Center to Advance Palliative Care, New York, 2013. 4. Weissman DE: Consultation in palliative medicine. Arch Intern Med 1997;157:733–737. 5. Berra Y: When You Come to a Fork in the Road, Take It!: Inspiration and Wisdom from One of Baseball’s Greatest Heroes. Hyperion, New York, 2002. 6. Weissman DE, Meier DE: Identifying patients in need of a palliative care assessment in the hospital setting: Consensus recommendations. J Palliat Med 2011;14:1–7.
(Figures follow/)
206
NOTES FROM THE EDITOR
Indications for consultation referral
Work day
Complex symptom assessment and management Complex medical decisions Complex goal setting for end-of-life planning Conflict concerning goals of care between patient, family, and care team Complex disposition planning Diagnoses
Any real or potential life-threatening or life-limiting condition; for example: X Cancer—any stage X Chronic pulmonary, cardiac, renal, or liver disease X Progressive neurological illness X Chronic vascular insufficiency X Diabetes with serious complications The following conditions fall outside the Scope of Services: X Chronic nonmalignant pain with no serious/lifelimiting illness X Assessment and management of a substance-abuse disorder X Routine advance care planning X Patient or family questions about hospice benefit/ services
The work day begins at 8:00 a.m. and ends at 5:00 p.m.; staying beyond 5:00 p.m. for patient care duties is strongly discouraged. Team check-in rounds occur at 8:30 and 1:00 to review cases, plan for team member attendance at family meetings, ensure coverage of new consultations, and provide support to team members. Consultation requests are triaged into emergency, urgent, and elective categories; emergency consultations take priority and will be seen within one hour of the request Monday to Friday. New consultations are seen the day of the request; when not possible, the requesting clinician will be contacted and informed. Consultation processes
Consultation management options
The palliative care team will provide interdisciplinary services as indicated by the referral question and patient/ family needs.
A one-time visit where the referring clinician seeks an opinion concerning a focused problem (e.g., prognosis and eligibility for hospice services). A co-management role with the referring clinician for care of a specific issue(s); the palliative care team will provide daily visits and, if requested, will assume order writing privileges for a defined role (e.g., symptom management). Attending physician duties for in-hospital or posthospital hospice services. Team members are not able to provide post-hospital attending clinician services for long-term care or assisted living facilities.
Availability
Full consultations: Monday to Friday 8:00–5:00. Nights and weekends: Emergency consultations will be managed by the on-call clinician and may include inhospital assessment. Non-emergency referrals will be managed by telephone.
FIG. 1. Palliative Care Consultation Service: Scope of Services (SAMPLE).
A new palliative care consultation includes assessment of physical, social, psychological, and spiritual dimensions. Requests by a referring clinician to limit consultation scope will be strongly discouraged. Complete symptom assessment data is recorded in the medical record on new consultations and repeated very 72 hours; symptom severity is recorded daily for moderate-severe symptoms. Whenever possible, all new consultations are staffed by both a palliative care physician and an advanced practice nurse, either together or sequentially. All patients are seen by at least two different disciplines of the palliative care team; consultations concerning complex symptom management or complex medical decisions will be at a minimum by the palliative care physician and/or the advanced practice nurse. Family meetings for goals of care discussions will be staffed by a palliative care physician and/or an advanced practice nurse. Family meetings will have a pre-meeting with the relevant care team members. Family meetings will be debriefed immediately following the meeting to assess and support team members. Prior to hospital discharge, one team member will review the plan of care with a goal of ensuring smooth transition management: post-hospital clinician follow-up, family education, medication reconciliation, symptom control. Prior to discharge to a hospice program or other postacute care service provider, one member of the palliative care team will contact a receiving clinician to review the plan of care. The team will consider ‘‘signing off’’ when there are no further issues relevant to the team’s Scope of Service.
FIG. 2. Palliative Care Consultation Service: Service Standards (SAMPLE).
NOTES FROM THE EDITOR Referring clinician relationship
Prior to visiting the patient/family, the referring clinician is contacted face-to-face or by telephone to obtain consultation information. The referring clinician or designated surrogate is contacted immediately following the consultation, face-to-face or by telephone, with consultation information/recommendations. Verbal or face-to-face contact with the referring clinician is made daily Monday to Friday. The referring and/or primary outpatient attending physician is invited to participate in family goals of care meetings. The referring physician is contacted when the team is considering ‘‘signing off.’’
207
1. Needs assessment: What are the opportunities/ barriers for programmatic growth?
Review program data: operational, clinical, customer, financial Identify/talk with key stakeholders Complete an environmental scan of your setting/ community 2. Define program goals: What are you hoping to achieve?
Clinical care Staff education Improving the system of care Improving health system outcome metrics Community education
3. Define outcome measures: How will we know if we are making a difference?
Miscellaneous
All patients will be encouraged to complete an advance care planning document naming a surrogate decision maker. Community DNR bracelets will be offered prior to discharge to all patients with DNR orders. Requests for information about community hospice providers will be referred to the appropriate hospital staff. Team physicians will not agree to take over inpatient attending responsibilities if asked by the referring clinician without consulting the full team.
FIG. 2.
(Continued).
Clinical Educational/behavioral Health system/financial
4. Define the resources/budget needed to meet program goals
Program staff Education Marketing Data collection/analysis
5. Test and implement the plan
Test assumptions with stakeholders/revise plan Develop a well-defined Action Plan to operationalize the plan
FIG. 3.
Strategic Planning Process Steps.
Address correspondence to: David E. Weissman, MD, FAAHPM Froedtert Hospital 8700 West Wisconsin Avenue Milwaukee, WI 53226 E-mail: [email protected]
Copyright of Journal of Palliative Medicine is the property of Mary Ann Liebert, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Notes from the Editor
Improving Care during a Time of Crisis: The Evolving Role of Specialty Palliative Care Teams David E. Weissman, MD, FAAHPM, Founding Editor
M
uch of my work over the past 10 years has focused on supporting the growth and sustainability of hospital palliative care teams. In that capacity I’ve had the pleasure to meet with dozens of teams and learn of their successes and struggles. The good news is that over the past 5 years there has been an unprecedented rise in the demand for inpatient and outpatient clinical services coming from both clinicians and administrators. The downside is that most teams I meet with are struggling, overwhelmed by the workload demands. I find that teams have staff with great clinical knowledge and skills, but often lack staff with knowledge and experience in navigating these stressors, such as strategic and business planning and human resource management. Faced with growing clinical demands, teams follow a predictable path, whereby they increase their clinical workload at the expense of data collection, education, quality improvement, and most importantly, team health. An early warning sign is when teams abandon teaching opportunities and provision of interdisciplinary care; increasingly I visit teams where each staff member has their own panel of patients with no crossdisciplinary engagement, violating a foundational precept of palliative care. As teams struggle to meet new demands, they inevitably ask for additional staff, often met with administrative indifference, in part due to the teams’ inability to adequately make the case for more resources in a manner that aligns with health system priorities, leading to staff frustration and further deterioration in team function. In prior editorials I have written about the dangers of being a team martyr and how teams can embrace the new reality of increasing clinical demand by starting to shift some of their work to support increased generalist-level palliative care training and system-change efforts.1,2 Although I find some teams working to embrace these ideas, far too many are trapped in an unproductive cycle of feeling overwhelmed and underappreciated. In this editorial I outline some concrete steps teams can take to move forward.
1. Self Care/Team Care
A principle of palliative care is that before you can help a patient establish goals, physical symptoms need to be well managed. Similarly, before teams can move forward they need to openly address issues of team health and correct dysfunctional team behaviors, including martyrdom. Since palliative care specialist clinicians are a scare resource, all teams need a proactive strategy for both prophylactic and interventional team health. At a minimum, teams should complete a self-assessment of team function and develop a
plan for consistent activities to both assess and promote improvements in team health.3 2. Workload Assessment
Teams are buffeted by increasing demands for clinical services and by new administrative imperatives to expand services to new patient populations and new care venues. Most teams approach these requests as if they have no voice in decision making, not wanting to offend administrators or colleagues who request their services. Thus, a key step is for teams to step back, take a deep breath, and gain some control over their own destiny. A few key questions can begin the process:
Are there opportunities to change daily work processes to increase efficiency without abandoning core palliative care principles? Are there patients that no longer need team follow-up in which the team can ‘‘sign off’’? Are there frequent consultations that are outside staff knowledge/skills? Are there frequent consultations that are outside the program scope of practice? What percentage of consultations represent generalistlevel palliative care, as compared to true specialistlevel consultations? Can some of the generalist-level requests be managed by curbside advice, rather than a full consultation?
Once these questions are discussed and teams recognize the gap between current and desired practice, they need to give themselves permission to set boundaries around their services and set program goals that realistically match their resources. Some will argue that setting limits around consultation practice has the potential to anger referring clinicians, leading to a drop in consultation volume. In the past, when we often struggled to prove our value, this was a reasonable concern. But such is not the case anymore for programs that are growing beyond their resources. Setting limits is a natural evolutionary step in program development that reinforces the notion that we are a true specialty, rather than a ‘‘feel-good’’ service for any and all needs of sick patients. 3. Scope of Services
Most teams, at the time of program inception, develop a marketing message including indications for referral. But seldom do I see teams make changes in how they market themselves as their program grows. The most common issues I see
204
NOTES FROM THE EDITOR
teams struggle with as they get busier are how to handle requests for chronic nonmalignant pain management, substance abuse assessment, hospice informational visits, and requests to manage time-intensive procedures such as a planned ventilator withdrawal. Each team needs to decide the relative value of their time and expertise in handling these and similar requests, in comparison to the more traditional palliative care specialty consultations for symptom management, conflict resolution, goal setting, and discharge planning.4 To help teams realign their resources with current clinical demands, I encourage all teams to develop a Scope of Services document, reassessed annually, that outlines four domains: indications for referral, diagnoses suitable for referral, consultation management options, and team availability (see Fig. 1). 4. Service Standards
Service standards define how a team operationalizes their day-to-day work. This is vital information both for the team itself, especially when new staff are added, and for referring clinicians. Establishing a list of service standards is an excellent team building exercise that, like the Scope of Services, should be reviewed annually. Key domains of service standards include daily work process, interactions with referring clinicians, and other components specifying the whodoes-what-when of the interdisciplinary team (see Fig. 2). 5. Strategic Planning
Strategic planning is a process to define a program’s goals and make decisions on how to achieve those goals based on available resources, or in the words of Yoggi Berra, ‘‘If you don’t know where you are going, you might not get there.’’5 Strategic planning for palliative care teams involves an analysis of current work, assessment of opportunities for new services, appraisal of staffing resources necessary to expand into new programmatic areas, and making a plan to operationalize the steps necessary to achieve the desired goals (see Fig. 3). Strategic planning involves the palliative care team and key stakeholders, including health system administrators, key clinicians, and others necessary to get the big picture of how palliative care services can best impact the health care enterprise. Program leaders who are unsure of how to go about a strategic planning process can usually find someone from hospital administration to help guide the process. Summary
The five elements outlined here should not be thought of as linear steps to be completed in the order of presentation, but rather a cycle of work processes. A natural starting point is to first work on team health and complete a strategic planning process and workload assessment, with subsequent changes made to the Scope of Practice and Service Standards. As teams work through the five elements they should also ponder their potential to impact the local health care culture beyond specialist consultations. I find that many teams are fixated on increasing their consultation volume as the key measure of value and impact. Indeed volume is one measure of how well the palliative care team is viewed by referring clinicians. But focusing on consultation volume alone limits the vision of
205
what palliative care, as a force for culture and practice change, can achieve. Forward-thinking hospitals and health systems are starting to recognize that palliative care services represent more than an end-of-life service line; palliative care concepts that are widely integrated can have positive impacts that ripple through all aspects of the institution and improve outcome metrics that administrators care about. If I were a hospital administrator, I would want the specialty team to spend no more than 50% of their time seeing consultations, and the other 50% working on elements of systems/culture change with a goal of improving the care of all patients with unmet palliative care needs, not just those fortunate enough to be referred for consultation.6 Furthermore, I would change how palliative care clinicians are evaluated for productivity, from a system based on clinical patient volume and billing to one focused on culture change that brings about a true system of patient-centered care. Systems change work includes educating our colleagues in generalist-level palliative care, developing screening pathways to identify patients with unmet needs, patient/family and community education, quality improvement processes, and establishment of standards, tools, and metrics to improve and measure patient-centered care.2,6 Granted, most palliative care clinicians today view themselves as clinicians first, rather than as agents for system change or education. And yet, when I meet with teams, it is the lack of culture change (e.g., ‘‘Why did the emergency physician admit this dying patient to the intensive care unit’’ or ‘‘Why did this patient suffer for three days with severe pain before they called us?’’) that is an ever-present source of team distress. In the early days of our specialty, the vision of palliative care was that it could positively impact the cure at all costs culture of health care and help shift care from clinician-centered to patient-centered. Starting a specialty consultation service was viewed as one of many important building blocks in realizing this goal. To fully realize that early vision, specialist teams can continue their good clinical work, but also seek out opportunities to change the larger culture of care through systems change and education. As a first step, teams need to remind themselves that they have control over how they meet the increasing demands for their time and services through self and team care, defining the boundaries of their services, and strategic planning. References
1. Weissman DE: Palliative care martyrs. J Palliat Med 2011; 14:1279–1280. 2. Weissman DE: Next gen palliative care. J Palliat Med 2012; 15:2–4. 3. Altillio T, Dahlin C, Remke SS, et al.: Strategies for maximizing the health/function of palliative care teams. Center to Advance Palliative Care, New York, 2013. 4. Weissman DE: Consultation in palliative medicine. Arch Intern Med 1997;157:733–737. 5. Berra Y: When You Come to a Fork in the Road, Take It!: Inspiration and Wisdom from One of Baseball’s Greatest Heroes. Hyperion, New York, 2002. 6. Weissman DE, Meier DE: Identifying patients in need of a palliative care assessment in the hospital setting: Consensus recommendations. J Palliat Med 2011;14:1–7.
(Figures follow/)
206
NOTES FROM THE EDITOR
Indications for consultation referral
Work day
Complex symptom assessment and management Complex medical decisions Complex goal setting for end-of-life planning Conflict concerning goals of care between patient, family, and care team Complex disposition planning Diagnoses
Any real or potential life-threatening or life-limiting condition; for example: X Cancer—any stage X Chronic pulmonary, cardiac, renal, or liver disease X Progressive neurological illness X Chronic vascular insufficiency X Diabetes with serious complications The following conditions fall outside the Scope of Services: X Chronic nonmalignant pain with no serious/lifelimiting illness X Assessment and management of a substance-abuse disorder X Routine advance care planning X Patient or family questions about hospice benefit/ services
The work day begins at 8:00 a.m. and ends at 5:00 p.m.; staying beyond 5:00 p.m. for patient care duties is strongly discouraged. Team check-in rounds occur at 8:30 and 1:00 to review cases, plan for team member attendance at family meetings, ensure coverage of new consultations, and provide support to team members. Consultation requests are triaged into emergency, urgent, and elective categories; emergency consultations take priority and will be seen within one hour of the request Monday to Friday. New consultations are seen the day of the request; when not possible, the requesting clinician will be contacted and informed. Consultation processes
Consultation management options
The palliative care team will provide interdisciplinary services as indicated by the referral question and patient/ family needs.
A one-time visit where the referring clinician seeks an opinion concerning a focused problem (e.g., prognosis and eligibility for hospice services). A co-management role with the referring clinician for care of a specific issue(s); the palliative care team will provide daily visits and, if requested, will assume order writing privileges for a defined role (e.g., symptom management). Attending physician duties for in-hospital or posthospital hospice services. Team members are not able to provide post-hospital attending clinician services for long-term care or assisted living facilities.
Availability
Full consultations: Monday to Friday 8:00–5:00. Nights and weekends: Emergency consultations will be managed by the on-call clinician and may include inhospital assessment. Non-emergency referrals will be managed by telephone.
FIG. 1. Palliative Care Consultation Service: Scope of Services (SAMPLE).
A new palliative care consultation includes assessment of physical, social, psychological, and spiritual dimensions. Requests by a referring clinician to limit consultation scope will be strongly discouraged. Complete symptom assessment data is recorded in the medical record on new consultations and repeated very 72 hours; symptom severity is recorded daily for moderate-severe symptoms. Whenever possible, all new consultations are staffed by both a palliative care physician and an advanced practice nurse, either together or sequentially. All patients are seen by at least two different disciplines of the palliative care team; consultations concerning complex symptom management or complex medical decisions will be at a minimum by the palliative care physician and/or the advanced practice nurse. Family meetings for goals of care discussions will be staffed by a palliative care physician and/or an advanced practice nurse. Family meetings will have a pre-meeting with the relevant care team members. Family meetings will be debriefed immediately following the meeting to assess and support team members. Prior to hospital discharge, one team member will review the plan of care with a goal of ensuring smooth transition management: post-hospital clinician follow-up, family education, medication reconciliation, symptom control. Prior to discharge to a hospice program or other postacute care service provider, one member of the palliative care team will contact a receiving clinician to review the plan of care. The team will consider ‘‘signing off’’ when there are no further issues relevant to the team’s Scope of Service.
FIG. 2. Palliative Care Consultation Service: Service Standards (SAMPLE).
NOTES FROM THE EDITOR Referring clinician relationship
Prior to visiting the patient/family, the referring clinician is contacted face-to-face or by telephone to obtain consultation information. The referring clinician or designated surrogate is contacted immediately following the consultation, face-to-face or by telephone, with consultation information/recommendations. Verbal or face-to-face contact with the referring clinician is made daily Monday to Friday. The referring and/or primary outpatient attending physician is invited to participate in family goals of care meetings. The referring physician is contacted when the team is considering ‘‘signing off.’’
207
1. Needs assessment: What are the opportunities/ barriers for programmatic growth?
Review program data: operational, clinical, customer, financial Identify/talk with key stakeholders Complete an environmental scan of your setting/ community 2. Define program goals: What are you hoping to achieve?
Clinical care Staff education Improving the system of care Improving health system outcome metrics Community education
3. Define outcome measures: How will we know if we are making a difference?
Miscellaneous
All patients will be encouraged to complete an advance care planning document naming a surrogate decision maker. Community DNR bracelets will be offered prior to discharge to all patients with DNR orders. Requests for information about community hospice providers will be referred to the appropriate hospital staff. Team physicians will not agree to take over inpatient attending responsibilities if asked by the referring clinician without consulting the full team.
FIG. 2.
(Continued).
Clinical Educational/behavioral Health system/financial
4. Define the resources/budget needed to meet program goals
Program staff Education Marketing Data collection/analysis
5. Test and implement the plan
Test assumptions with stakeholders/revise plan Develop a well-defined Action Plan to operationalize the plan
FIG. 3.
Strategic Planning Process Steps.
Address correspondence to: David E. Weissman, MD, FAAHPM Froedtert Hospital 8700 West Wisconsin Avenue Milwaukee, WI 53226 E-mail: [email protected]
Copyright of Journal of Palliative Medicine is the property of Mary Ann Liebert, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
