Community-Based Palliative Care in Rural Oregon

May 3rd 2019

Dr. Stephen Kerner and Donna Becker MSW

Objectives Discuss ways to develop and sustain community-based

palliative care programs in rural communities.

Explore techniques to address the challenges inherent in rural palliative care.

The Peace Harbor Community-Based

Palliative Care Program

The Community Located on the Oregon coast Population:

– Florence = 8,800 people– Mapleton = 918 people– Deadwood, Swisshome = approximately 500 people– Peace Harbor’s patient panel = 18,000

Retirement community – 36.4% of population is over the age of 65-years-old (2010 census)– Volunteerism

Our demographic area – approximately 950 square miles

Palliative Care ProgramObjectives and Goals

Improve the quality of life for patients and their families Offer compassion, psychosocial, and spiritual support Improve access and continuity of care Provide education to patients and families regarding the disease

process and advance care planning Eliminate and/or decrease needless and unwanted

hospitalizations and Emergency Department (ED) visits Coordinate care with community partners

PresenterPresentation NotesMultiple sources of literature review for program development including CAPC, AAHPM, OHA etc

Program Scope Available Monday through Friday from 8 a.m. to 5 p.m.

– Offer 24-hour coverage to facility patients only Serving patients in 7 different local facilities (memory care,

assisted living, foster homes) Now admitting the highest need home-based patients

– Usually home bound Serving patients discharged from hospice (no longer

meeting hospice admission criteria) and have significant difficulty getting into the clinic for appointments.

The Team• Dr. Stephen Kerner – Board-Certified

Hospice & Palliative Care Physician • Marti Manko – Nurse Practitioner• Suzan Larson – Medical Office

Assistant (MOA)• Donna Becker – Medical Social

Worker• Marti Free – Chaplain • Kyla AndrewsMcNew – RN /

Program Manager• Volunteers – 29 current volunteers

PresenterPresentation NotesContinue to develop multidisciplinary team.

Offer a “primary care” model of Palliative Care– Dr. Kerner resumes as the Primary Care Provider for most of

our patient population• Increases time requirements for patients• Helps patients:

o Less confusion about who to call for whato Helps our team to manage care better – we are tending to all symptoms,

medication needs, etc. Less likely to go to the Emergency Department or the hospital.

The Volunteer Program Offer companionship, support, and respite care Licensed Massage Therapist Transportation volunteers Office Volunteers Check-In Volunteer Pet Care program

The Patients Current census of approximately 85 to 105 patients

– 2/3 of patient population resides in a facility– 1/3 of patient population in their own home

Our program has served over 311 patients thus far We have approximately 35 to 40 pending patients at

any given time.– Averaging 8-9 admissions per month.– Averaging 6-7 discharges per month.– Averaging 16-17 new referrals per month.

Program Success Stories Community Support:

– Before the business plan was completed and approved, we had funding available for the first 2 years of the program (community and staff donations + one grant).

We have an active and thriving Palliative Care Volunteer Program.– Over 1600 hours donated in 2018.

Completed/revised over 140 Physician Orders for Life Sustaining Treatment (POLST) forms – this assures that patient’s wishes are respected at end-of-life.

We are maintaining sustainability due to Dr. Kerner’s ability to bill for services. As a result, we were able to hire a Nurse Practitioner for our team.

Increased hospice census and length of stay (LOS)

Chart1

201620162016

201720172017

201820182018

Census

2

3

Hospice Census

14.4

18.4

20.8

Sheet1

Census23

201614.4

201718.4

201820.8

Chart1

201620162016

201720172017

201820182018

Series 1

Column1

Column2

Hospice Length of Stay

65.9

64.6

78.8

Sheet1

Series 1Column1Column2

201665.9

201764.6

201878.8

Increase in Home Health referrals, census and episodes of care

0

2

4

6

8

10

12

14

16

18

20

1 2 3 4 5 6 7 8 9 10 11 12

Dr. Kerner’s Episodes of Care

• Reducing unnecessary Emergency Department visits and hospitalizations• If a facility calls with an urgent patient need, Dr. Kerner

can usually arrange to see the patient either the same day or the next day.

Reduction in Emergency Room Visits and Hospitalizations –patients from local facilities

0

5

10

15

20

25

30

35

2014

0720

1408

2014

0920

1410

2014

1120

1412

2015

0120

1502

2015

0320

1504

2015

0520

1506

2015

0720

1508

2015

0920

1510

2015

1120

1512

2016

0120

1602

2016

0320

1604

2016

0520

1606

2016

0720

1608

2016

0920

1610

2016

1120

1612

2017

0120

1702

2017

0320

1704

2017

0520

1706

2017

0720

1708

2017

0920

1710

2017

1120

1712

2018

0120

1802

2018

0320

1804

2018

0520

1806

2018

0720

1808

2018

0920

1810

Outpatient Observation Inpatient

Palliative Care:The Challenges of Rural

Communities

The Challenges Staffing and Resources

– Recruiting Palliative Care Team Members in rural settings– Striving to offer interdisciplinary support– Offering coverage that meets patient’s needs and team goals– Time – optimizing the skills and time available with small teams– Funding (staffing, supplies, operation costs, etc.)– Accessing medical services (labs, imaging, etc.)

Working with several Electronic Medical Records (EMRs)

Managing referrals– Creating capacity to manage new referrals and current patients

Demonstrating Program Value– Tracking statistics and metrics– Balancing value-based services in a fee-for-service world– Patient Experience Surveys

Education– Providers and staff– Community partners and facilities– Community

Addressing the Challenges

Staffing and Resources Recruitment

– It took our team 18 months to recruit a Nurse Practitioner– Finding qualified providers

• Willing to train the right candidate

Striving to offer interdisciplinary support to our patients– Started with physician, social worker, and medical office assistant– Recognized the need to offer comprehensive services:

• Added a chaplain to our team with Foundation funding• Advocating for nursing support• Advocating for mobile labs and imaging

Offering coverage that meets the patient needs and team goals– Able to offer 24-hour support to facility-based patients only– Recruited 2 other providers to help with call schedule– Still unable to offer 24-hour support to home-based patients

Time – optimizing the skills and time available with a small team in a rural setting– Maintaining regular contacts with patients

• Assuring that a team member is connecting with patients on a regular basis (telephone, in-person visits)

– Formed collaborative relationship with Mobile Integrated Healthcare worker (Community Paramedic)

• Works with our team one day per week and “as needed” during the week– Formed collaborative relationship with clinic nurse care

coordinator• Works with our team one afternoon per week

– Formed collaborative relationship with local surgeon – willing to do home visits

– Use of Volunteer Program:• Respite and companionship volunteers • “Check-In” Volunteer

o Calls all home-based patients/caregivers once per week o Uses a “call script” to assess for needso Helps to identify patients with more urgent needs (medications, new symptoms,

etc.)

– Travel time• Grouping visits – rounding at the facilities on specific days, seeing

several patients in the same vicinity on the same day

Funding– Community Support – continue to receive regular donations for

our program– Dr. Kerner and Marti’s ability to bill for services– Ongoing relationship with Peace Harbor Foundation to access

support for highest needs (i.e., chaplain)– Continuously looking for funding opportunities including private

donations, grants, collaborative relationships with our CCO

Improving patient access to medical services– Mobile Integrated Healthcare worker has been drawing labs for

all home-based, homebound patients– Exploring ways to offer mobile phlebotomy, laboratory and

imaging services– Our program belongs to a larger healthcare system – specialists

including Cardiology, Urology, Oncology, etc. come to Florence on a regular basis.

Electronic Medical Records Dr. Kerner has to work with several EMRs – our program’s

EMR, local facilities each have their own EMR, and our Home Health and Hospice team has their own EMR

Difficulty with Medication Reconciliation, getting updated notes, etc. – our Medical Office Assistant is constantly requesting records and updating our EMR

Managing Referrals Receive 13-16 new referrals every month

– Increased awareness of the program in our community Wait list – continued to grow during 2018

– Recognizing the need is higher than expected

Referral sources– Approximately 35-45% from Primary Care Providers, 20-30%

from local care facilities • Education regarding appropriate referrals• Education about the wait list• Contact all referrals to inform them of the wait list• Urgent situations – can usually see them within a few days

Establish eligibility criteria and defining population to serve– Started slow – facility patients only and hospice discharges

• Gradually added highest need home-based patients o Homebound and cannot access medical careo Patients without a Primary Care Providero Frequent Emergency Department visits and hospitalizations

– Use a Screening Tool to help prioritize patients– Continuously re-evaluating eligibility criteria and discharging

patients who are no longer appropriate.

– Recommend completing a Community Needs Assessment to define program criteria; assure you are meeting the needs of the target population.

Demonstrating Program Value Continuously tracking program statistics and metrics

– Using volunteers for data entry– Running quarterly and annual reports

• Assuring this information is distributed to people who need to see it

Balancing value-based services in a fee-for-service world– Support from administration

• Providing more community-based services• Goal of eliminating unnecessary and unwanted ED visits• Preventing hospital readmissions

Completed a 12-question Patient Experience Surveys– Received positive feedback regarding what is working well and

where we need to make some changes– Will continue to do annual surveys

Education Accepting offers for community education

– Completed over a dozen presentations about Palliative Care• Community organizations, faith communities, etc.• Provider meetings, clinic staff, hospital staff• Facility staff meetings

– Balancing increased community awareness with rising number of referrals

Community-Based Palliative Care in Rural Oregon�ObjectivesThe Peace Harbor �Community-Based�Palliative Care Program The CommunityPalliative Care Program�Objectives and Goals Program ScopeThe TeamSlide Number 8The Volunteer ProgramThe Patients Program Success StoriesSlide Number 12Slide Number 13Slide Number 14Slide Number 15Reduction in Emergency Room Visits and Hospitalizations – �patients from local facilitiesPalliative Care:�The Challenges of Rural CommunitiesThe ChallengesSlide Number 19Addressing the ChallengesStaffing and ResourcesSlide Number 22Slide Number 23Slide Number 24Slide Number 25Slide Number 26Electronic Medical Records Managing ReferralsSlide Number 29Slide Number 30Slide Number 31Demonstrating Program Value Slide Number 33Education Slide Number 35