Building a Palliative Care Program Mark Angelo, MD, FACP Cooper University Hospital

Overview The playing field The playing field Making the pitch Making the pitch Contract negotiation Contract negotiation The players The players Price of admission Price of admission Game play Game play Moving forward Moving forward

DEFINING THE PLAYING FIELD Building a Palliative Care Program

Needs Assessment Survey of hospital needs – Inpatient Consult or Primary Service – Outpatient – Geriatric service or inpatient unit – Subacute or LTAC setting – ICU – ED – Peds

Needs assessment Your needs – Personal – Professional – Social/ family – Remuneration Needs of referral base (docs and RNs) – Formal survey

Formal Survey What is the unmet need for the referring practitioners? Estimate workflow This is your warning shot to work up a buzz in the organization

The Stakeholders Hospital or hospice administrators Department chair Nursing Director / CMO Oncology center leadership Foundation leaders Ethics Board

The Stakeholders What can YOU offer THEM ? Motivating points: ICU-LOS, throughput, bottom line, Accreditation, patient care

Mission Alignment Make a mission statement It must align with that of your stakeholders and institutional priorities.

Data Collection Hospital death rates Press-Gainey or other patient satisfaction data Readmissions (especially for chronic diseases) LOS data as compared to region Dartmouth data for your region Supportive anecdotal data

Overview the Pall Care Literature What can Palliative Care do for: – ICU LOS? – Cost? – Geriatric care management – Pain scores vs. anesthesia pain management service? – Resource utilization? – Readmission rates? – Patient and family satisfaction?

The Pitch Building a Palliative Care Program

Presenting to Your Stakeholders Improved patient care and satisfaction scores Improved patient flow Cost savings*: – For live d/c about $1600 per admission (direct costs) p=.004 – For hospital death $4900 per admission (direct costs) p =.003 >70% of hospitals with >250 beds have these programs *Arch Int Med. 2008; 168(16):

Selling Points (cont’d) Improved pain and symptom control Palliative care represents patient centered, compassionate, ethically appropriate, and socially responsible medicine.

CONTRACT NEGOTIATIONS Building a Palliative Care Program

Different Models Hospital supported – (Department / Division / Program / Unit) Hospice supported Stand alone Palliative Medicine practice

Different Models Hospital supported – (Department / Division / Program / Unit) Hospice supported Stand alone Palliative Medicine practice.

Which team to chose? Consider the organization or department with the greatest need for the target of your alignment Go with the team that will give you the most referrals Who has the influence, resources, space and money? – Oncology, Geriatrics, Medicine, Hospitalists, Nursing, Social Services

Who will be the General Manager? Palliative care expertise Leadership ability Administrative liaison Time to see patients and devote to a program

THE PLAYERS Building a Palliative Care Program

The Players Need a physician champion Need a nurse champion What other personnel can you borrow? (SW, psychology, pastoral care, dieticians, Pharm.D) All the players together make up the TEAM Encourage palliative care certification for all.

80% of success is showing up. Woody Allen

How will you deliver? Inpatient rounds Outpatient hours Vacation and on-call coverage ICU presence ED availability Training program

PRICE OF ADMISSION Building a Palliative Care Program

The price of admission… Securing start-up funding: – Hospital Support – Individual / organization backed – Philanthropy – Grants – Once patient care starts reliance more on patient revenue *

Presenting the Business Plan Executive Summary Financial / Budget Summary Operational Plan for Implementation Institutional and Market Analysis Marketing Plan Appendix

PLAYING THE GAME Building a Palliative Care Program

Palliative Care – WHO definition improves the quality of life of patients and their families facing the problems associated with life- threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual

The Essentials National Consensus Project of Palliative Care – Clinical Guidelines for Quality Palliative Care – Found at

Domains of Quality Palliative Care 1.Structure and Processes of Care 2.Physical Aspects of Care 3.Psychological and Psychiatric Aspects of Care 4.Social Aspects of Care 5.Spiritual, Religious and Existential Aspects of Care 6.Cultural Aspects of Care 7.Care of the Imminently Dying Patient 8.Ethical and Legal Aspects of Care

Building upon your success Regular connections with case managers, utilization review, hospitalists, department chairs Rounding with ICU team Weekly IDT meeting Lecture, lecture, lecture Handouts

No two programs are identical Your program will be designed to meet the needs of YOUR patients, stakeholders, and referral base

MOVING FORWARD Building a Palliative Care Program

Goal Setting – First Year Get the word out Establish working patterns Build referral base Begin a paradigm shift in the delivery of care in the institution Firming up relationships with partners (hospice, home care, PT, IDT members)

Goal Setting – after the first year… Expansion of clinical efforts – consult triggers Research Educational Efforts Building philanthropic relationships Proactive examination of the business model – Review of services – Expansion in the areas of need, contraction where little impact demonstrated

Goal Setting – Long Term Becoming a fixture in the institution Geographic unit Training program – fellowship, nursing, med school curriculum Philanthropic Fund

WRAP-UP Building a Palliative Care Program

Summary Examine yourself and your institution for viability Establish funding Use the 8 domains by the consensus report Use the right people and be present Be proactive with an eye on growth

To get more information… Center to Advance Palliative Care ( Palliative Care Leadership Centers American Academy of Hospice and Palliative Medicine ( Fellow program directors

The End Mark Angelo, MD, FACP Director, Palliative Medicine Cooper University Hospital