1. Embedding Palliative Care in the Oncology Clinic:
Culture, Infrastructure, and Growth
Wednesday, June 12th , 2013
Audio Conference
1:00 - 2:00 PM EASTERN
Vicki Jackson MD,MPH
Chief, Division of Palliative Care
MGH, Department of Medicine
Harvard Medical School
Boston, MA
Simone Rinaldi MSN, ANP-BC, ACHPN
Co-Director, Outpatient Palliative Care Clinic
MGH, Department of Medicine
Boston, MA
Mihir Kamdar, MD
Co-Director, Outpatient Palliative Care Clinic
MGH, Departments of Medicine and Anesthesia Pain; Harvard Medical School; Boston, MA
Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only.

2. DISCLOSURE No Industry or Financial Disclosures Slide 2 of 43
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3. Our Story at MGH Building the Plane as We Flew It: Slide 3 of 43
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4. A History of MGH Outpatient Palliative Care
Began in 2003
No designated office space
Appts. scheduled according to patient availability (when seeing their oncologist)
PC availability key factor in building relationships
Staffed by 1 MD and 1 NP
½ day on 2x/week with 2-3 visits/week
No financial arrangement with oncology
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5. MGH Outpatient Palliative Care Ten Years Later
Volume increased 400 % over past 5 years
Annually
900 New Consults
2400 Follow up visits
5 MD, 2 NPs, and an Access RN
Covering 14 sessions
MD and NP Fellow Education
Medicine Residents
Visiting Observers
Expanding research agenda
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6. How Our Plane Looked in the Beginning...
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7. We’re getting there, but we’ve had to learn to embrace the turbulence!
How We Want it to Look...
We’re getting there, but we’ve had to
learn to embrace the turbulence!
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8. Outline of Today’s Audio Conference
Scope of an Embedded Practice
Who Do We See, Where and How We See Them
The Challenges of Scheduling
Access and Referral Management
Building and Maintaining Relationships with Referrers
Lessons Learned & Cases
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9. History Who Do We See? Defining Your Patient Population Slide 9 of 43
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10. Who Do We See at MGH? Primarily Cancer Patients 95%
Occasional Non-Cancer Patients 5%
CHF
ESLD
ESRD
ALS
Geriatric Pts with Multiple Co-Morbidities
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11. But Where/How You Embed May Depend on Your Institutions Needs
The Environmental Scan of your site:
Clinical Needs
Choose populations with high symptom burden and high resource utilization
Are there clinical groups with influence who want integration? Start there!
Financial Opportunities
For example, oncology was very supportive at MGH and was willing to split the losses for 2 years while the clinic got up and running
Educational Needs
To have an ACGME accredited fellowship must have a clinic
Research Agendas
Having an oncologist interested in studying palliative care facilitated integration at MGH
Institutional/Health System Goals
Decreasing re-admissions and length stay
Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only.
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12. Where It Can Get a Little Sticky...
Non-Cancer Pain
Cured but with Post-Treatment Pain
Patients with Substance Abuse Issues
Must think through…
Does our team have the expertise?
If not, who to partner with?
How do we want to be defined?
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13. How Do We See Them? Identifying the Ideal Model Slide 13 of 43
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14. Palliative Care Across the Continuum
Primary Palliative Care
Essential PC skills
Support that all providers should have at their disposal
to care for challenging patients
e.g. Education for all clinical providers
Some community based palliative care models
Secondary Palliative Care
Consultative only role with referring clinician
e.g. One time consultation with follow up as needed
Tertiary Palliative Care
Co-Management with referring clinician
e.g. Follow patient closely in all sites of care delivery
Quaternary Palliative Care
PC assumes full care of patient
e.g. Inpatient hospice, Inpatient Palliative Care Unit
Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only.
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15. Think About Your Model of Care
At MGH: Co-Management Model
Rare Exceptions-> Consultative Model
How Do You Want to Operate Your Clinic?
What are Your Available Resources?
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16. Issues of Space and Scheduling
Where Do We See Them?
Issues of Space and Scheduling
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17. Where Do We See Our Patients? Anywhere We Can Find Them!
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18. Defining Your Visit Parameters
Number of New and Follow-up Patients per Clinic Session?
A session is 6 patients with 2 new and
4 follow-up visits
High no show rates…do you want to overbook?
Time Allotment for New and Follow-up Visits?
New 60 minutes
Follow up 30 minutes
Number of Clinic Sessions per FTE?
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19. Defining Your Visit Parameters
Frequency of Follow-Up Visits
Opportunities for Joint Visits
Visits in Infusion or Other Sites
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20. The Complexities of Scheduling in an Embedded Clinic
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21. Models of Embedded Scheduling
Linked => PC visit at the same time as Oncology
Better utilization
More complicated, not always efficient
Compromises continuity with PC provider
Improves communication between referrer and oncology
Joint visits are possible
Unlinked => PC patients scheduled separately
High no show rate
Easier Scheduling
Better if limited number of Providers
Mixed Model => Separate Scheduling with urgent consults seen on same day
Newly developing programs often do this as part of marketing
Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only.
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22. The Challenges of Embedded Scheduling
Linking of Visits
Advantages and Complexity
Benefits of a Dedicated Scheduler
This is Not Straightforward - Must be skilled!
How comfortable is the person with talking about PC?
Must be educated in PC and be able to explain it to patients and families
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23. “If You Build It, They Will Come” Optimizing Access and Utilization
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24. Optimizing Access: Referral Management
Varying Models of Referrals Management
Currently Utilize Centralized Mailbox
Importance of:
Clear Reason for Referral
Denoting Urgency
Asking if Patient is Aware
Managing Requests for Same Day Visits
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25. Patient - Provider Communication
Optimizing Access:
Patient - Provider Communication
Daytime Phone Call Management
After Hours Calls
/Internet Communication?
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26. Optimizing Utilization
Challenges of Linked Visits
Dependent on oncology schedule
Late providers
Cancellation of chemotherapy
Phone-Based Visit Reminders
RN Access Nurse Pre-Visit Calls
Effective Urgent Triage can Help Utilization when Needed
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27. Thinking About the Details
The Nitty Gritty
Thinking About the Details
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28. Think About Who Will Handle:
Scheduling
Medical Assistants, Billing Specialists
Prior Authorizations
Script Refills
Medication Administration in Clinic
Day Time Calls
After Hour Calls
*Define these with your institution ahead of time...
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29. It Always Comes Down to Numbers
Metrics and Outcomes
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30. The Importance of Gathering Metrics
Identify Gaps in Clinic
Better Sense of Needs when Dealing with Leadership
Sample Metrics:
Access: Goal of <14 days
Utilization Rates
Symptom Scores: VAS etc.
Patient Satisfaction and Referrer Satisfaction
Building Data Collection Infrastructure Early
-> Better for Your Clinic
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31. Relationships with Oncology: How to Start And Nurture
You have a clinic…now what?
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32. We must define early integrated Palliative Care
Disease Modifying Therapy
DEATH
What is this care?
Palliative Care
Hospice
Diagnosis
Active Therapy
Dying
Bereavement
Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only.
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33. Early palliative care differs from inpatient consultation
Focus is on developing long-term relationships
More time to address difficult topics
Less often in crisis
Promotion of quality of life throughout the course of the illness
Care has the potential to be nebulous
Care is collaborative with oncology team
Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only.
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34. Cultures
Most oncologists value this work and many like doing it themselves
We must remember that when we are entering their world
How can we be of help?
They must learn how we do this work
Joint visits are very helpful to begin to understand the culture.
We must learn how they do this work
PC in oncology must know basic oncology
Take time to learn it
Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only.
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35. Collaboration Who does what?
Early in the integration must have explicit discussion with each provider
How can I be helpful to you in the care of this patient?
Do you want me to make recommendations to you about med changes or to prescribe myself?
How do you feel about me talking about prognosis if a patient asks?
How shall I communicate with you after I see the patient?
Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only.
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36. Many opportunities for miscommunication
Patients tell us different things
We don’t hold the key to chemotherapy
They don’t want to disappoint their oncologist
We ask differently
What was the patient really told?
Develop a differential diagnosis for this discrepancy
Hold oncologist in high regard
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Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only.

37. Building a referral base
Attend regular clinical meetings e.g. lung and GI cancer
If clinic is light, go visiting oncologists…
“Oh, hey, I have a patient in my office that I think might be good for you to see…”
Offer to see the patient together
Keep your door open…
“I have this tough patient, can I talk to you about them? Not sure what to do…”
Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only.
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38. Triggers can help build a clinic
Many times oncologists may be open to PC involvement but have not made it a routine part of care
Are there populations that oncology would agree should see palliative care?
Pancreatic and lung cancer
If all agree to this for certain patient populations, then could start as part of the team from diagnosis
Research data supports this model
Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only.
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39. “If We’d Known Then What We Know Now….”
Lessons Learned Over the Past Decade
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40. Outpatient PC interacts with Inpatient PC….
Must think about the outpatient team interacts with the inpatient team
Managing continuity
How do the two teams communicate and track patients?
Outpatient will drive up inpatient volume
Do you have staffing to accommodate?
Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only.
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41. Lessons Learned
We are not only serving the patients but very much serving the referrers
Learn basic oncology
Must be more skilled in symptom management than those referring to you
Be flexible
Hold them in high regard
Being an oncologist is hard
Develop a method for communication about challenges
Expect them they will happen
Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only.
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42. Question & Answer Period
Thank you for joining us today!
ABOUT CAPC
The Center to Advance Palliative Care (CAPC) provides health care professionals with the tools, training and technical assistance necessary to start and sustain successful palliative care programs in hospitals and other health care settings. CAPC is a national organization dedicated to increasing the availability of quality palliative care services for people facing serious illness.
Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only.
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43. Continue the Discussion on
CAPCconnectTM Forum!
At the conclusion of this audio conference,
we welcome you to continue the discussion with
your peers and faculty on CAPCconnectTM Forum!
Go to:
to post your message and comments within the
“Palliative Care Outpatient Services”
discussion topic!
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Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only.