1. Palliative Care at SOMC SOMC Grand Rounds Monday March 18 th, 2016

2. Palliative care is specialized medical care for people living with serious illness. It focuses on providing relief from the symptoms and stress of a serious illness—whatever the diagnosis. The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of palliative care doctors, nurses and other specialists who work together with a patient’s other doctors to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment. 1 What is Palliative Care? 1 Center to Advance Palliative Care 2011

3. Examples of patients with a serious illness that frequently benefit from a palliative approach include:  Difficult symptom control in chronic diseases like: COPD, CHF, CRF, etc.  Transfers from LTCF or other medical home  Metastatic or locally advanced incurable cancer – even if seeking chemo/radiation.  Advanced dementia (defined as needing assistance with ADL’s; limited to no coherent speech, limited to no ambulation, and incontinent) Who gets Palliative Care? Source: 2011 IPAL-EM Project, Center to Advance Palliative Care. Palliative Care ED Screening Tool

4. Our Vision - to provide quality care to patients in our community who suffer from a serious medical condition. Palliative Care teams improve quality of care and support both the patient and primary medical team by providing: Time to devote to intensive family meetings and patient/family counseling Expertise in managing complex physical and emotional symptoms such as pain, shortness of breath, depression and nausea Support and communication for resolving patient/family/physician questions concerning goals of care Coordination of care transitions across healthcare settings. Vision of Palliative Care at SOMC

5. The role and function of any palliative care team is to focus on improving the patients quality of life. This can be achieved through holistic, patient centered care in our community. The palliative care team will work to improve quality of life by focusing on these important healthcare areas: 1 Aggressive Symptom Management Advance Care Planning and Decision Support Psychosocial and spiritual support Communication and support for patient and family Provide guidance regarding medical decisions and technologies Guidance for transitions/care options Palliative Care Role 1 This focus of care is unique to palliative medicine

6. Palliative Care is medical specialty that focus on the care of those people with a serious or chronic medial condition. – The leading cause of death in the U.S. are all related to chronic medical conditions. (Cancer, Heart Disease, Pulmonary Diseases, etc.) Difficulties with chronic illness encountered throughout medicine: Nearly half of the adult population in the US suffers from chronic illness 1 50% of Medicare annual costs come from only 5% of the patients. 2 “Our current healthcare system is a mess because we take care of very sick people very poorly” 3 In Ohio, patients with a terminal condition average a 10 day hospitalization in their last 6 months of life. The national average is 9.8 days. 4 Why Palliative Care? 1. CDC, 2014 2. IOM, 2013 3. Russell K. Portenoy, MD, Metropolitan Jewish Health System (NYC), 2015 4. CAPC, 2013

7. Why palliative care? We already have hospice… The Palliative Care Umbrella – It’s more than just hospice “The Palliative Care Umbrella”

8. Why palliative care? It requires change… Palliative Care requires a shift from an treatment focused plan of care to a more consumer driven; patient centered, holistic plan of care. Change from… To this…

9. Palliative Care Screening Tool To qualify for palliative care, patients must have a serious, life-threatening illness** and one or more of the following:  Not Surprised - You would not be surprised if the patient died in the next 12 months  Bounce-Backs - More than one ED visit or hospital admission for the same condition within several months  Uncontrolled Symptoms - ED visit prompted by difficult-to-control physical or psychological symptoms  Functional Decline - Decline in function, feeding intolerance, unintentional weight loss or caregiver distress  Increasingly Complicated - Complex long-term care needs requiring more support How do we identify appropriate Palliative Care? Source: 2011 IPAL-EM Project, Center to Advance Palliative Care. Palliative Care ED Screening Tool.

10. PC House Calls and PC Home Health can be provided together or separate, based on patient needs. Inpatient Palliative Care A hospital service at SOMC where patients can benefit from palliative care consultative services during their hospitalization Coming: April 2016 Palliative Care: House Calls A provider based (NP) home service where the provider makes “house calls” to patients who are chronically ill and have difficulty with transportation, etc. August 2013 Palliative Care: Home Health Specialty palliative care service delivered to home health enrolled patients who have advanced symptom needs. February 2010 Hospice Palliative care service delivered to patients with a terminal illness; < 6 month life expectancy. Outpatient & Inpatient Services 1985 PC Cancer Center Clinic Referral based clinic that focuses on pain and symptom management in cancer patient undergoing treatment. Services are provided at SOMC Cancer Center. June 2014 PC Nursing Home Model Provided to residents at a nursing facility. Focus of care is on symptom management, communication and coordination of care. Does not replace NH primary physician. Currently at Piketon Nursing Center April 2015 What do we provide?

11. Consultative services provided at SOMC Main Campus. Team Includes: Hospitalist physician oversight and collaboration, palliative care experienced nurse practitioner, and medical social worker. Chaplains available by request. Consults for: pain management, symptom management, discharge planning, transitions, coordination of care, advance directive focus, discussions for advanced treatment and decision making The inpatient team will focus on discharge planning to ensure patient has necessary options for care at time of discharge. INPATIENT PALLIATIVE CARE Coordinating Care: Inpatient to Outpatient Hospice: Patient’s referred to hospice care from referral of the inpatient team will be admitted prior to discharge and hospice services will begin immediately post- discharge. PC House Calls: Patient’s referred to house calls program from referral of the inpatient team will be seen by a palliative care NP within 72 hours of discharge for assessment, medication reconciliation and advanced care need coordination. PC Home Health: Patient’s referred to the home health program from referral of the inpatient team will be seen by a home health nurse within 48 hours.

12. Services provided in the comforts of the patient's home by a Nurse Practitioner Patients DO NOT require ‘skilled need’ or ‘homebound status’ as defined by home health regulations. Visits are based on medical necessity: 1x/week, 1x/month, etc. Consults for: pain management, symptom management, observation, coordination of care, advance directive focus, discussions for advanced treatment and decision making These are ‘high risk’ patients. Therefore, they have access to a 24/7 on call RN & Provider On-Call Team. HOUSE CALLS PROGRAM The House Calls program can be in addition to the Home Health program or can be independent, based on pt. needs. The House Calls providers do not replace the patient’s PCP – our practitioner will update and collaborate with the physician to determine appropriate intervention and the optimal careplan for the patient. Services can be provided to the patient wherever they call home; at their residence or ALF. House Calls also currently has a collaborative agreement with Piketon Nursing Center (SNF).

13. Palliative Care: House Calls Outcomes

14. Quality Care by ED & Hospitalization Avoidance Time Period: 12 months (7/2014-7/2015) Comparison: Patient’s ED visit frequency before and after admission to House Calls program. Total Patients: 62 patients Results: Admission to the House Calls program resulted in: 56% reduction of ED visits (114 fewer) 54% reduction of hospitalizations (75 fewer)

15. Palliative Care: House Calls Outcomes Quality Care by ED & Hospitalization Avoidance Patient A: 16 ER 4 Hosp prior to House Calls 2 ER 1 Hosp after House Calls Patient B: 10 ER 4 Hosp prior to House Calls 1 ER 3 Hosp after House Calls Patient C: 11 ER 4 Hosp prior to House Calls 3 ER 1 Hosp after House Calls

16. Services provided in the comforts of the patient's home (SNF) by a Nurse Practitioner Visits are based on medical necessity: 1x/week, 1x/month, etc. Consults for: pain management, symptom management, observation, coordination of care, advance directive focus, discussions for advanced treatment and decision making These are ‘high risk’ patients. Therefore, they have access to a 24/7 on call RN & Provider On-Call Team. HOUSE CALLS: SNF PRACTICE The House Calls providers do not replace the patient’s PCP – our practitioner will update and collaborate with the physician to determine appropriate intervention and the optimal careplan for the patient. In the SNF, the PC NP teams up with the patient’s primary physician and nursing team to help with advance careplanning and hold discussions for advance directives and difficult decision making concerning the patient’s medical treatment options.

17. Palliative Care at PNC Piketon Nursing Center (PNC) Location: Overlook Drive in Piketon, OH – 3 mi to Adena-Pike – 19 mi to Holzer (Jackson) – 22 SOMC – 26 Adena (Chillicothe) Max Capacity: 46 beds Average % Occupied: 85-85% FY2015 (39-41 patients) Palliative Care Consults (4/2015-12/2015): 25 (14 on current PC roster) Hospice Consults 2015: 5

18. Consultative services provided at SOMC Cancer Center every Wednesday afternoon Team Includes: Palliative Care LPN and Palliative Care NP. Consults for: advanced pain & symptom management, coordination of care, advance directive focus, discussions for advanced treatment and decision making 2007 American College of Chest Physicians (ACCP) & American Society of Clinical Oncology (ASCO) recommendation that all patients with metastatic non-small cell lung cancer be offered palliative care along with standard cancer therapy CLINIC AT SOMC CANCER CENTER Impact of PC Clinic: Patients receive aggressive symptom management to help with treatment compliance and completion. Physicians/Oncologist – more time to devote on cancer treatment plan Oncology team – improve/better symptom management of patients Home Health/Hospice – Improve coordination of referrals and transitions in a timely manner Cancer Committee – meet current accreditation requirements (ACOS Standard 2.4)

19. Palliative Care Outcomes House Calls and Cancer Center Clinic Outcomes Timeframe: 9/2015 – 2/2016 Average House Call Census: 55 patients (31 visits/month) Average Cancer Center Census: 14 (17 visits/month) Average ED Visits/Month: 2 Total # Death on PC: 7 Total Hospice Referrals: 27

20. The patient’s PCP is our main collaborator and will assist in providing an effective plan of care for the patient and family Services can be provided to the patient in their home or at an Assisted Living Facility. The home health program can not go into a SNF.. Services Include: Skilled Nursing (Case Management & Crisis Management), Home Health Aid Services, Social Work Services, & Therapy Services Patients require ‘skilled need’ and ‘homebound status’ to receive services Visits are based on medical necessity: 1x/week, 2x/week and continue weekly until the skilled need is resolved Consults for: pain management, symptom management, observation, etc. Patient’s have access to 24/7 on call nursing services – nursing visits to home. HOME HEALTH PROGRAM

21. Blending two programs to provide a comprehensive service to our community Hospice care is limited to patients with a limited prognosis and doesn’t allow aggressive, curative treatments. – Hospice care is known in the U.S. to save money and to keep patient’s in their home until the end. Blending the philosophy of hospice care into home health allows us to tap into expertise and knowledge of hospice care and deliver an appropriately needed and quality service to our community – All palliative care staff has unlimited access to hospice expertise for pain and symptom management. – Interdisciplinary IDT consisting of the palliative care team and hospice staff meet monthly to discuss patient care plans and goals of care. Components of the Home Health Program

22. “A Home Health Program with a Hospice Philosophy” What We Do… -Education – Nurses provide education to patients regarding advance care planning, goals of care and treatment options. -Time - the palliative care nurses take time to discuss the illness, treatments and end of life discussions as appropriate. -Coordination – due to the diverse training, the nurses are experts in transitional care. The nursing staff is knowlegable of the various programs of palliative care and transitions are seamless. Is this program dependent on prognosis? Palliative Care: Home Health can be delivered at any time of the patients illness and is not dependent on prognosis or current treatments. Palliative Care: Home Health may also be a good option for those patients who have been referred to hospice care but they are “not ready yet”. Components of the Home Health Program **Blending the home health and hospice programs allows us the opportunity to provide appropriate and quality services to our community.

23. Services Palliative Care RN – Case Manager – The palliative care case manager (RN) is the family’s point person for all care needs and questions. This allows for continuity and establishment of rapport which is crucial for the difficult case management these patients require. – Home Telehealth monitoring is also available for daily monitoring of vitals. 24/7 Crisis Management – Dealing with a chronic disease is difficult. Palliative Care: Home Health provides 24/7 on-call nursing support for patient and families. Social Services Consult – Palliative care focuses on holistic care. Social services are offered to all patients to help with the emotional and social burdens of a chronic illness. Spiritual Support – **Chaplain services are unique to the hospice benefit, but there are ample opportunities within our community. We have and will continue to provide education to our local spiritual leaders to encourage their involvement in these unique cases. Components of the Home Health Program Community Clergy Education Opportunity: Putting the Pieces Together 5/12/15 & 5/26/15

24. INPATIENT Imminent Death admissions are usually viewed as prognosis <72 hours. This is not exclusive. Respite Admission – Under hospice, patients receive 5 respite days each month to help alleviate caregiver strain. Patient’s can elect to utilize respite at any point of their illness, including at time of admission.. Caregiver Crisis – i.e. Family not ready for patient to return home, uncertain prognosis, etc. Pain/Symptom Mgmt. – Patient is still having difficulty in managing pain/symptoms, but is medically cleared to be D/C’d from hospital. OUTPATIENT & INPATIENT Very Specific Patient Population No Aggressive Treatment Terminal Illness Needed (<6 Months) Most Common Form of Palliative Care Currently OUTPATIENT Outpatient Hospice can follow a patient wherever they call home: residence, SNF, Assisted Living Facility, Group Home, etc. Services: Nursing (Case Management & Crisis Management), Social Services, Volunteer, Chaplain, Therapy, Dietary, and Short-term inpatient care. Bereavement services are also offered to families after the patient passes. Patients do not have to be DNR – if patient wish for Full Code, outpatient staff will address accordingly and ongoing.

25. Summary Our vision at SOMC is to provide quality palliative care to patients in our community who suffer from a serious medical condition. Palliative Care teams improve quality of care and support both the patient and primary medical team.

26. Safety  Quality  Service  Relationships  Performance Any Questions? Any Questions?