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Palliative care gets patients to right care level
Consult team works closely with case managers
At Summa Health System, hospital case managers, called patient care coordinators, often are the first people to alert the palliative care team when a patient could benefit from a consultation and the first people the team contacts to find out what's going on with a particular patient.
"Ultimately, palliative care gets the patients in the right place at the right time for the right level of care. We can collaborate with the patient care coordinators to facilitate their discharge plan by helping the family understand the options," says Kim Kousaie, BSN, CHPN, director of Palliative Care and Hospice for Summa Health System.
Summa Health System is a nonprofit health care system in northeastern Ohio with three teaching hospitals and 1,235 licensed beds.
Palliative care is not typically reimbursed by insurance, but it can pay for itself by shortening hospital and intensive care stays, Kousaie points out.
The program is an outgrowth of Hospice of Summa, which includes a separate 12-bed palliative care unit and palliative consult service. The acute palliative care unit addresses patients' immediate needs until they are stable enough to go home or to another level of care. The average length of stay on that unit is three to five days.
At Summa Health System, the palliative care consult service has two nurse practitioners and two physicians and a palliative medicine fellow, who make between 120 and 130 new consultations each month with patients and family members on the medical-surgical units and intensive care unit.
They move around the hospital, assessing patients who might benefit from palliative care and facilitating medical and comfort care for patients.
The palliative care consult team consults on patients with a disease crisis who need symptom management and an interdisciplinary team to coordinate their care.
"Patients in palliative care have a serious or life-threatening illness and are looking at end-of-life issues, even if their illness won't become terminal for some time," Kousaie says.
When the palliative consult service started, the nurse practitioner and physician would attend the intensive care unit rounds and review with the team any patient who had been in the ICU for 14 days or longer.
In the rest of the hospital, the palliative care nurse practitioner works with the patient care coordinator, unit manager, social worker, and home care assessment nurse to review their patients and make recommendations when appropriate.
The palliative care team works with the treatment team and hospital staff to provide symptom management, patient and family support, comprehensive end-of-life care when appropriate, and discharge planning when patients can be moved to another level of care.
"We let them know when a patient is appropriate for palliative care. We've educated the hospital staff so they understand that the palliative care team can help hold a discussion with the family that facilitates the discharge plan and gets patient moved to the palliative care unit or home with hospice services," Kousaie says.
To be eligible for a palliative care consultation, patients must have a life-threatening illness, such as cancer, end-stage heart failure, or a severe stroke.
"Our approach to palliative care is not limited to terminally ill patients. Our patients range from active treatment to noncurative care. Every care plan is unique," Kousaie says.
The team has recommended rehabilitation services for some patients with severe strokes. They've gone through rehabilitation and done well.
"We've had patients with end-stage liver disease who were on the transplant list and we managed their symptoms successfully until they had the transplant and moved on," Kousaie says.
The palliative care team gathers information from the patient's treatment team and meets with the family to present the options.
"When we are called in for a consultation, the patient care coordinator is the first person we see because they are aware of everything that is going on with the patient. They are the people who can give us information about family dynamics and other issues that may not appear in the chart," Kousaie says.
When the palliative care team meets with the patient and family members, it helps the patient and family members understand the meaning of what the physicians have told them, what it means for the patient in the future, what their treatment options are, and the likely outcomes of each option, she explains.
"The physicians sometimes lay out so many options that the family doesn't know what they are answering to. The physicians sometimes don't present the true scope of the long-term effect of the treatment. That's what palliative care does. We finish the sentence for the physician," Kousaie says.
For instance, a physician may say the next step is a tracheotomy and a percutaneous endoscopic gastrostomy tube but the family may not understand that the process is only going to prolong the patient's life, not provide a cure.
"Nobody wants to tell a mother that giving her daughter more care is futile. We try to help the family understand what is happening and what the result of the each option is likely to be," she says.
Team educates family
The team educations the family on what "do not resuscitate" (DNR) orders mean, what comfort care means, and what they believe is likely to happen with the patient.
"We are a victim of our own success. We have been so successful at team meetings and at facilitating family meetings that we have almost enabled the physicians not to deal with end-of-life issues but to call us in instead," she says.
When the palliative care consult service began in 2001, the intensive care unit was its first target.
"It's the logical place to start. When the ICU fills up, the hospital may go on diversion and lose revenue, and sometimes there are patients in the ICU who do not benefit from additional treatment," she says.
The team started by looking at the mortality rate for patients who were in the intensive care unit for 14 days or longer.
"We determined that patient mortality could be predicted sometime between 14 and 30 days in the ICU," she says.
Part of the vision for the program was to educate the medical professional about the benefits of palliative care, Kousaie says.
The team put together an educational program about the benefits of palliative care and the services the consult program offered and presented at every medical and nursing department in the system.
"The patient care coordinators became the core group of people we focused on to educate them about what palliative care can offer and how it can help facilitate the discharge plan and get the patients moved to the right level of care. We wanted to educate them so when they work with patients who could benefit from palliative care, they'll have the information they need to approach the physician and ask for a palliative care consultation," she says.
The team continues to use every opportunity to educate the health care team about what palliative care means, she says.
CMs in position to make a difference
Even if their hospitals don't have a palliative care program, case managers are in a position to help patients and their families when situations arise where they may benefit from palliative care, Kousaie says.
"If case managers see a family struggling, they can talk to the family to get a sense of what they need, then present it to the physician, and suggest that palliative care might be appropriate," she says.
Gather all the information you can, talk to the family, and present the entire package to the physician.
Kousaie suggests that case management directors facilitate an inservice educational session on how to facilitate a family meeting.
"If case managers learn how to initiative those difficult conversations and feel comfortable talking about palliative care and end-of-life issues, it can be of great benefit and comfort to the patient and family," she says.
(For more information, contact Kim Kousaie, BSN, CHPN, Director of Palliative Care and Hospice for Summa Health System; e-mail: KousaieK@summa-health.org.)