Community Care Brooklyn (CCB), a Performing Provider System (PPS) in New York’s Delivery System Reform Incentive Payment (DSRIP) Program, is partnering with the MJHS Institute for Innovation in Palliative Care on Project 3.g.i., the integration of palliative care into the Patient-Centered Medical Home (PCMH). Palliative care is a model focused on populations of patients with serious chronic illness, which aims to reduce the suffering and illness burden of the patient and the family from the time of diagnosis forward. The Palliative Care Project created through the partnership between CCB and the MJHS Institute will pursue this goal through education of primary care providers and the implementation of specific practice support through patient screening, dissemination of guidelines for best practices, and outcomes tracking.
Through the Palliative Care Project, CCB will achieve the following New York State-required program elements for Project 3.g.i.:
1) Development of a strong partnership with a community provider of palliative care supports and services
2) Development and adoption of clinical guidelines and protocols focused on key best practices for generalist-level (“primary”) palliative care
3) Engagement of PCMH staff in training to increase role-appropriate competence in primary palliative care skills, and
4) Identification and tracking of actively engaged patients for project milestone reporting
During an 18-month period, the Palliative Care Project will develop, implement, and assess a two-pronged initiative intended to promote best practices in generalist-level palliative care through an integrated and multifaceted program of provider education and practice support.
The Education Program of the Palliative Care Project
The education program of the Palliative Care Project has been designed to engage primary care physicians, nurses, and social workers through the presentation of state-of-the-art information in multiple formats over a sustained period of time. The elements include:
- The MJHS Institute will live-stream 14 monthly webinars, each of which will be available subsequently as enduring online material. Each webinar—live-streamed and online—will provide continuing medical education (CME) credit. Topics include pain and symptom management in the medically ill, communication and goal setting, prognostication, and the role of the hospice benefit.
- The key ‘takeaways’ discussed in each webinar will be summarized in a brief fact sheet. These “Palliative Care Reviews,” will be released at the time of the live-streamed event and will be subsequently posted as enduring online material.
- The MJHS Institute also will live-stream 14 monthly case conferences, each moderated by a palliative medicine specialist. These innovative 30-minute conferences will present a challenging management problem posed by a patient with serious illness and described in a narrative presented on slides. After the live-streamed event, the case conference will be available as enduring online material. Both the live-streamed and online conference will provide CME credit.
- Nurses working in the CCB network will have access to three “Webinar Workshops”, each 2-hour long live-streamed events offering education about palliative care from the perspective of nursing practice. Each workshop will cover a different set of topics and will be available subsequently as enduring online material. Both the live-streamed and online workshops will provide continuing education units (CEUs).
- Social workers working in the CCB network also will have access to three, 2-hour long “Webinar Workshops”, each offering education about palliative social work. Each live-streamed workshop also will be available subsequently as enduring online material, and both will provide continuing education units (CEUs).
- For patients served by the Patient-Centered Medical Home, the MJHS Institute will develop and produce educational brochures on topics related to serious illness and palliative care, including self-monitoring and management of pain and other symptoms, advance directives, life-prolonging treatments, prevention of re-hospitalization, and hospice services. Brochures will be available in multiple languages and distributed to the practices in electronic and hard copy versions.
The Practice Support Program of the Palliative Care Project
The MJHS Institute will work closely with selected practices to implement an innovative model of practice support. The model, described in a Practice Support Resource Manual, includes workflows, tools, guidelines, and questionnaires. Implementation will be customized for each practice and will be designed to minimize staff burden while addressing the most common problems encountered in palliative care. The first goal is to identify patients with serious chronic illness who express varied types of distress or illness burden. The second goal is to engage these patients in an intervention that targets illness burden by providing physicians ready access to specific protocols for primary care management of pain, breathlessness, anxiety and depression; advance care planning discussions; and hospice eligibility review and discussion. The third goal is to track outcomes through repeated measurement using a validated questionnaire, the Palliative Outcome Scale. The elements include:
- A workflow for patient identification that includes practice-level screening and a very brief two-phase screening at the time of intake. Screening tools are available in multiple languages and may be implemented electronically or through hard copy.
- Specific management protocols based on widely accepted guidelines designed to become a point-of-care resource through integration into the electronic medical record. These protocols will support physician decision-making for symptom management—specifically pain, breathlessness, anxiety and depression—and provide guidance about communication strategies intended to improve the experience of advance care planning and support the patient’s ability to access hospice when medically eligible.
- A workflow for repeated completion of the Palliative Outcome Scale, combined with the availability of the questionnaire in multiple languages, that will provide information about outcomes, which may additionally inform the primary care provider’s decisions about management.
- Patient education materials that are configured for printing in the physician’s office and can be used to support palliative care activities at the point-of-care.
Together, the education and practice support represents an unprecedented and novel strategy to achieve meaningful improvement in the care of populations with serious chronic illness while achieving the goals of DSRIP. The Palliative Care Project will:
- Achieve the goals of Project 3.g.i. through partnership with a community organization, engagement of patient with identified needs, engagement of professionals through dissemination of guidelines that enhance the care of the seriously ill, and tracking of outcomes related to this care.
- Meaningfully increase the awareness of palliative care and its integration into the Patient-Centered Medical Home.
- Increase the likelihood that seriously ill patients can minimize hospitalization late in the course of a serious chronic illness because care at home is adequate.
- Enhance the clinical competency of individual professionals in several key domains of palliative care, including the management of common symptoms, ensuring the availability of legal and accessible advance care plans, and providing information about hospice and eligibility review.