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 vjackson@partners.org Simone Rinaldi MSN, ANP-BC, ACHPN Co-Director, Outpatient Palliative Care Clinic MGH, Department of Medicine Boston, MA sprinaldi@partners.org Mihir Kamdar, MD Co-Director, Outpatient Palliative Care Clinic MGH, Departments of Medicine and Anesthesia Pain; Harvard Medical School; Boston, MA mmkamdar@partners.org Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only.

DISCLOSURE No Industry or Financial Disclosures Slide 2 of 43 Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Slide 2 of 43

Our Story at MGH Building the Plane as We Flew It: Slide 3 of 43 Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Slide 3 of 43

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 Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Slide 4 of 43

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 Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Slide 5 of 43

How Our Plane Looked in the Beginning... Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Slide 6 of 43

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! Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Slide 7 of 43

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 Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Slide 8 of 43

History Who Do We See? Defining Your Patient Population Slide 9 of 43 Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Slide 9 of 43

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 Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Slide 10 of 43

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. Slide 11 of 43

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? Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Slide 12 of 43

How Do We See Them? Identifying the Ideal Model Slide 13 of 43 Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Slide 13 of 43

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. Slide 14 of 43

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? Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Slide 15 of 43

Issues of Space and Scheduling Where Do We See Them? Issues of Space and Scheduling Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Slide 16 of 43

Where Do We See Our Patients? Anywhere We Can Find Them! Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Slide 17 of 43

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? Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Slide 18 of 43

Defining Your Visit Parameters Frequency of Follow-Up Visits Opportunities for Joint Visits Visits in Infusion or Other Sites Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Slide 19 of 43

The Complexities of Scheduling in an Embedded Clinic Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Slide 20 of 43

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. Slide 21 of 43

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 Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Slide 22 of 43

“If You Build It, They Will Come” Optimizing Access and Utilization Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Slide 23 of 43

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 Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Slide 24 of 43

Patient - Provider Communication Optimizing Access: Patient - Provider Communication Daytime Phone Call Management After Hours Calls Email/Internet Communication? Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Slide 25 of 43

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 Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Slide 26 of 43

Thinking About the Details The Nitty Gritty Thinking About the Details Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Slide 27 of 43

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... Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Slide 28 of 43

It Always Comes Down to Numbers Metrics and Outcomes Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Slide 29 of 43

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 Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Slide 30 of 43

Relationships with Oncology: How to Start And Nurture You have a clinic…now what? Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Slide 31 of 43

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. Slide 32 of 43

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. Slide 33 of 43

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. Slide 34 of 43

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. Slide 35 of 43

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 Slide 36 of 43 Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only.

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. Slide 37 of 43

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. Slide 38 of 43

“If We’d Known Then What We Know Now….” Lessons Learned Over the Past Decade Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only. Slide 39 of 43

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. Slide 40 of 43

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. Slide 41 of 43

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. Slide 42 of 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: http://www.capc.org/forums to post your message and comments within the “Palliative Care Outpatient Services” discussion topic! Slide 43 of 43 Copyright 2013 Center to Advance Palliative Care. Reproduction by permission only.