Julie S's Profile

Rob-we have seen and have similar issues that we have worked through and continue to work through. I am an Oncologist, so have many palliative care discussions, referrals, and now with palliative care providers embedded within our service line as a “matrix” of care. Our palliative care program started as inpatient services only, and has grown to outpatient services, including outreach clinic sites. This has been a work in progress, and the change happens slow, but does happen. We have found that involving the community has been helpful, as the population ages, the “boomers” are interested in these discussions, and often are the drivers for additional information.

Some of the things we have done to improve referrals and awareness include:
-embedding a palliative care provider within the physical space of departments with high referrals and usage (the opposite of “out of sight, out of mind”, is when I see and interact with our palliative care colleague every day, I send more patients, and am able to talk with patients about these members of THEIR team)
-we initially embedded outpatient palliative care providers several half days a week, and grew within 6-12 months to need full time coverage
-we met as physicians within Oncology to determine what patients would be appropriate for automatic referrals…metastatic solid tumors such as lung cancer, colon cancer, breast cancer, etc. Locally advanced cancers with poor prognosis such as pancreatic cancer, etc.
-we empowered our Nurse Practitioners and Nurse Navigators and support staff with education regarding palliative care services, and benefit for patients
-we include our palliative care physicians in our Oncology Service Line physician journal club on a monthly basis, and ask that they bring a pertinent ariticle from that month regarding palliative care
-we include and invite palliative care providers to every tumor board conference/meeting on a weekly basis
-we have a palliative care representative on cancer committee for the organization
-our inpatient palliative care intersects/does a warm hand-off for transitions from inpatient to outpatient palliative care follow up
-our palliative care providers have engaged the community with educational talks and open forums/discussion on the benefit of palliative care
-our CEO writes a column for the local newspaper every week. Palliative Care benefits was a recent topic, with many patients bringing in the article to their physicians, wanting to discuss in regards to their health
-our inpatient palliative care team rounds with the ICU and hospitalist teams on a daily basis
-patients may also self-refer to palliative care
-we did find that some of the greatest barriers are physicians who feel that perhaps they are doing the job of palliative care already, and therefore do not see the benefit of referral
-our palliative care department tracks metrics, and brings those forward on a quarterly basis
-our palliative care providers have done inservices with departmental and hospital staff, including education on DNR/POLST forms/difficult conversations/listening well initiatives, etc.
-over time, this has become more “habit” as the service grows, and physicians and staff understand the benefit to patients and families. Understanding that “it takes a village”, and that myself as a physician am not always the most skilled person for every need a patient may have.
-When I see a new patient with advanced cancer, we assess “distress” at that and each visit. We have a guide of distress 4/10 or greater warrants further discussion and referral to MSW or palliative care
-I/we often have our palliative care providers in the exam rooms and present during the physician visit. The patients and families come to expect this, and consider those providers as part of their team. A patient asked me this week, when I introduced the palliative care RN during the visit what palliative care meant. Of course their are many answers….I like the answer of “In some ways they function in as a interpreter and advocate of your needs, goals, values, wishes, side effects, decisions etc., for you and your family with your treatment team. Sometimes physicians and patients and families think they are on the same track and goal, but come to find out perhaps more discussion is needed….”

Thank you Neil. The culture of the leadership groups felt they were aligned. However, the impact to the thousands of employees was not appreciated until post-affiliation. Lessons learned….discuss as much at every level prior to changes (discuss as much is legally allowed during the exploratory phases for example), set up “listening circles”, or “town halls” for discussion and questions, and evaluate/measure physician and employees satisfaction, engagement, prior to affiliation, with specific attention to how an affiliation or merger would change their alignment, etc. All of that has happened to a great deal post-affiliation.

Make the dashboard relevant to the physician’s day to day practice, and easy to read and interpret, otherwise not likely to be used. Also…accurate data is important/required. For example, at our institution, on our dashboard we recieve individually our production vs budgeted RVUs, etc. It turned out that 2 FMLA’s of employees within the billing department happened within the same month, and billing and dropping of E&M charges lagged by 4-6 weeks as a result. The physician’s saw their dashboard substantially change, but not concordant with their actual work done. This caused “panic” to say the least, to have physician’s pay be so closely tied to RVU production month to month, and 30% drops were seen with many providers. After many days to several weeks, eventually the root cause was seen. So…if you use/develop a dashboard so linked to pay and production, if their is a system’s issue…be prepared to inform quickly those that need to rectify that information, as provider and physician satisfaction otherwise will loose trust in the dashboard’s accuracy.

We have seen a shift in our region of the country to the employers themselves driving where some procedures are performed, based on cost of care and quality of care, with contracts negotiated based on these metrics for specific procedures, including hip and knee replacement. For example..Boeing with contracts in the Mid-West to have non-emergent CABG performed out of state, etc. We are seeing this shift with total hip and total knee, forcing patients to travel 100-200 miles to recieve their treatment from their home based on decreased out of pocket expense if the preferred clinic/system is used for the procedures. So my question is…do you have estimates on your cost of care for specific orthopedic procedures, and quality measures that are associated, that you could present to the local employers and companies in this apparently very competitive market place?

I think you will see a substantial improvement in efficiency and patient satisfaction by “bringing the resources to the patient”, such as dedicated days of the week for Breast Cancer Clinic, or GI malignancy Clinic, or Liver tumor Clinic, etc. The patients and families would have the benefit of being seen the same day by the surgeon, medical Oncologist, and Radiation Oncologist on the same day, and meet with their other team members at the same time, such as a Nurse Navigator specific to that disease. Also consider having a mini-tumor board on those days where the more difficult cases are discussed by the multi-disciplinary team. I am a Medical Oncologist, caring for adult patients with cancer. We are not an academic center, but with schedule all of these appointments on the same day for the patients and families, and have found improved satisfaction, improved understanding of the plan moving forward, and buy-in from the team. When I refer a patient to an academic center for a specific oncology diagnosis, for example “Sarcoma”, that patient is seen by the sarcoma surgeon, med onc, rad onc, etc., on the same day, in the same clinic location. So these disease specific clinics are housed within Medical Oncology, with the surgeons, etc., coming for that day or half day with the understanding that their focus will be on patients who have a common cancer. The medical assistants, schedulers, receptionists, nurse navigators, etc., have found improved job satisfaction and improved efficiency. Bringing the MDs on board to this idea will by default bring the staff on board.