Models for Operationalizing Supportive Care in Kidney Care

2020 ◽  
pp. 36-46
Author(s):  
Dale E. Lupu ◽  
Emma Murphy
Keyword(s):  
Chronic Kidney Disease ◽  
Palliative Care ◽  
Supportive Care ◽  
Medical Management ◽  
Positive Impact ◽  
Care Planning ◽  
Program Success ◽  
Disease Case ◽  
Advance Care ◽  
The Impact

The field of kidney supportive care is in a period of innovation, with different models emerging from local efforts to improve care. We classify emerging models into six types: embedded, mobile/visiting, chronic kidney disease case management, medical management without dialysis, concurrent hospice/dialysis, and comprehensive regional or system-wide programs. Although individual programs have demonstrated positive impact on outcomes such as advance care planning and place of death, there is not yet systematic evidence comparing the impact of model type on effectiveness or cost effectiveness. Local considerations about need, resources, opportunities, and champions are key to planning a supportive kidney care strategy. Facilitators for program success include training for nephrology providers, active collaboration between nephrology and palliative care, local champions (often nurses), sensitive messaging about medical management without dialysis, and research to demonstrate program impact.

scholarly journals Innovative Models for High-Risk Patients Use Care Coordination and Palliative Supports to Reduce End-of-life Utilization and Spending

2017 ◽  
Vol 1 (2) ◽  
Author(s):  
Sarah Ruiz ◽  
Lynne Page Snyder ◽  
Katherine Giuriceo ◽  
Joanne Lynn ◽  
Erin Ewald ◽  
...  
Keyword(s):  
Palliative Care ◽  
Supportive Care ◽  
End Of Life ◽  
Care Coordination ◽  
Cost Of Care ◽  
Care Transition ◽  
Care Planning ◽  
Care Model ◽  
Advance Care

Abstract Background and Objectives Care coordination and palliative care supports are associated with reduced anxiety, fewer hospital admissions, and improved quality of life for patients and their families. Early palliative care can result in savings in the end-of-life period, but there is limited evidence that larger-scale models can improve both utilization and the cost of care. Three models that received Health Care Innovation Awards from the Centers for Medicare & Medicaid Services aimed to improve quality of care and reduce cost through the use of innovative care coordination models. This study explores the total cost of care and selected utilization outcomes at the end-of-life for these innovative models, each of which enrolled adults with multiple chronic conditions and featured care coordination with advance care planning as a component of palliative care. These included a comprehensive at-home supportive care model for persons predicted to die within a year and two models offering advance care planning in nursing facilities and during care transitions. Research Design and Methods We used regression models to assess model impacts on costs and utilization for high-risk Medicare beneficiaries participating in the comprehensive supportive care model (N = 3,339) and the two care transition models (N = 587 and N = 277) who died during the study period (2013–2016), relative to a set of matched comparison patients. Results Comparing participants in each model who died during the study period to matched comparators, two of the three models were associated with significantly lower costs in the last 90 days of life ($2,122 and $4,606 per person), and the third model showed nonsignificant differences. Two of the three models encouraged early hospice entry in the last 30 days of life. For the comprehensive at-home supportive care model, we observed aggregate savings of nearly $19 million over the study period. One care transition model showed aggregate savings of over $500,000 during the same period. Potential drivers of these cost savings include improved patient safety, timeliness of care, and caregiver support. Discussion and Implications Two of the three models achieved significant lower Medicare costs than a comparison group and the same two models also sustained their models beyond the Centers for Medicare & Medicaid Services award period. These findings show promise for achieving palliative care goals as part of care coordination innovation.

Embedded Palliative Care for Amyotrophic Lateral Sclerosis: A Pilot Program and Lessons Learned

2021 ◽  
pp. 10.1212/CPJ.0000000000001124
Author(s):  
Kelly Fahrner-Scott ◽  
Carly Zapata ◽  
David L. O’Riordan ◽  
Eve Cohen ◽  
Laura Rosow ◽  
...  
Keyword(s):  
Palliative Care ◽  
Advance Care Planning ◽  
Lessons Learned ◽  
Pilot Program ◽  
Care Planning ◽  
Aid In Dying ◽  
Advance Care ◽  
Pain Symptoms ◽  
The Impact ◽  
Lateral Sclerosis

AbstractBackground:Palliative care (PC) is recommended for people with amytrophic lateral sclerosis (ALS), but there is scant literature about how to best provide this care. We describe the structure and impact of a pilot program that integrates longitudinal, interdisciplinary PC into the care of patients with ALS.Methods:Observational cohort study of patients with ALS referred to outpatient PC and seen for at least three PC visits October 2017-July 2020.Results:Fifty-five patients met inclusion criteria. Three-quarters (74.5%) were Caucasian and 78.2% spoke English. Patients were referred for advance care planning (58.2%), support for patient/family (52.7%), and symptoms other than pain (50.9%).Patients had a mean of five scheduled PC visits, the majority occurred by video. A PC physician, nurse, social worker, and chaplain addressed pain (for 43.6% of patients), non-pain symptoms (94.5%), psychosocial distress (78.2%), spiritual concerns (29.1%), care planning (96.4%), and supported family caregivers (96.4%).With PC, the rate of completion of advance directives increased from 16.4% to 36.4% (p=0.001) and Physician Orders for Life-Sustaining Treatment forms from 10.9% to 63.6% (p<0.001). Of the 27 patients who died, 77.8% used hospice, typically for more than 30 days. Eleven patients obtained aid-in-dying prescriptions and eight took these medications, accounting for 29.6% of the deaths.Conclusions:Integrating longitudinal, interdisciplinary PC into the care of patients with ALS is feasible, addresses needs in multiple domains, and is associated with increased rates of advance care planning. Controlled studies are needed to further elucidate the impact of PC on ALS patients, families, and clinicians.

Integration of palliative care for patients with solid tumors on phase I clinical trials.

2016 ◽  
Vol 34 (26_suppl) ◽  
pp. 138-138 ◽  
Author(s):  
Betty R. Ferrell ◽  
Vincent M. Chung ◽  
Marianna Koczywas ◽  
Anna Cathy Williams ◽  
Arti Hurria ◽  
...  
Keyword(s):  
Palliative Care ◽  
Clinical Trials ◽  
Phase I ◽  
Symptom Burden ◽  
Care Planning ◽  
Phase I Clinical Trials ◽  
Advanced Directives ◽  
Care Services ◽  
Advance Care ◽  
The Impact

138 Background: Cancer patients receiving Phase I clinical trials are a population with advanced disease, high symptom burden, and with multiple QOL concerns including use of advance directives. Methods: An NCI funded R01 is currently in progress (2014-2019) as a randomized clinical trial to test a palliative care intervention (PCI) in this population. The PCI includes comprehensive patient assessment, goals of care communication, interdisciplinary care planning and patient teaching. Aims and hypotheses test the impact of the PCI on symptoms, QOL, resource use, spirituality and distress. Outcomes for the study (N = 400) will be conducted at the conclusion of the RCT. This paper reports preliminary baseline data of the first 100 subjects accrued. Results: Subjects mean age was 59 years and 59% were female, similar to prior trials. Forty eight percent (48%) were ethnic minorities, higher than prior trials (3% non-white, Finlay E, 2014; 9%, Parsons JA, et al. PLoS One 2012) with colon (22%) and lung (21%) cancers as dominant. Patients had a mean of 2 comorbidities (range 0-8) and 40% of the patients are > 65 years of age. The most common symptoms reported by PRO-CTCAE (1 = least to 5 = most concern) were sexuality (4.2), fatigue (2.9), pain (2.6) and anxiety (2.5). Psychological Distress Thermometer, (0 - least to 10 = most distress) mean score was 4. FACIT spiritual concerns (1 = least to 5 = most concerning) identified greatest concerns of illness strengthening faith (2.0), strength from faith (2.0) and sense of harmony (2.6). There was limited use of supportive care services, PC consultation, or advanced directives. Conclusions: The population of Phase I trial patients is an important group for palliative care integration with major unmet needs in symptom management and advance care planning.

MO171BARRIERS TO RENAL SUPPORTIVE CARE IN SINGAPORE: A SURVEY BASED STUDY OF NEPHROLOGISTS, GERIATRICIANS AND PALLIATIVE PHYSICIANS

2021 ◽  
Vol 36 (Supplement_1) ◽  
Author(s):  
Yan Ting Chua ◽  
Santhosh Seetharaman ◽  
Priyanka Khatri
Keyword(s):  
Chronic Kidney Disease ◽  
Palliative Care ◽  
Kidney Disease ◽  
Supportive Care ◽  
Community Support ◽  
Public Hospitals ◽  
Care Planning ◽  
Advanced Care Planning ◽  
Asian Countries ◽  
Care Training

Abstract Background and Aims Renal supportive care is a patient-centred approach to management of advanced chronic kidney disease, especially in elderly patients. Adoption of renal supportive care in Asian countries has been slow. This study aims to investigate the barriers towards renal supportive care as perceived by physicians in Singapore. Method An online survey was sent out to all practising and training nephrologists, geriatricians and palliative physicians in Singapore public hospitals between October 1st and October 30th 2020. Responses were compiled and analysed. Results Out of 365 surveys sent, 75 nephrologists, 43 geriatricians and 28 palliative care physicians responded, accounting for a 40% response rate. Most of the participants managed 16 to 30 chronic kidney disease patients in a week. Older patients aged &gt;75 years accounted for at least 30% of the chronic kidney disease cohort managed by 72% of respondents. Most agreed that renal supportive care aims to improve quality of life in chronic kidney disease (97.9%) and can be implemented alongside life-prolonging treatments such as dialysis (83.6%). However, only 51.4% recognised a distinction between renal supportive care and palliative care. Fewer nephrologists compared to geriatricians received prior palliative care training (54.7% vs 93.0%) or were certified advanced care planning facilitators (33.3% vs 67.4%). All respondents agreed that nephrologists should be aware of basic principles of palliative care, and 89.7% felt that palliative care should be incorporated into nephrology training. Most were comfortable holding discussions regarding dialysis withholding and withdrawal (93.8% and 87.7% respectively), and managing symptoms of pain (74.7%), breathlessness (87.0%) and anticipated symptoms after dialysis withdrawal (78.8%). Fewer physicians were comfortable with managing symptoms of pruritus (65.1%) and restless legs syndrome (56.2%). Majority (60%) did not feel confident in providing spiritual support as part of end-of-life care. Main barriers to renal supportive care included inadequate time during clinic consults to address the patients’ needs (87%), reliance on family members to make decisions (69.2%), inadequate palliative training during fellowship (67.1%) and inadequate community support services (55.5%). Some cited lack of awareness and acceptability of renal supportive care amongst patients and relatives in Singapore’s Asian cultural context. Most felt that encouraging advanced care planning discussions earlier in the course of chronic kidney disease (80.8%), having dedicated renal supportive care services in hospital (78.1%) and including palliative care rotation as part of training (69.2%) could potentially increase uptake of renal supportive care in Singapore. Conclusion Nephrologists, geriatricians and palliative physicians in Singapore recognise the value of renal supportive care, but are faced with barriers such as patients’ and family’s resistance toward renal supportive care as well as inadequate palliative training. A unique model of renal supportive care with the patient as well as family’s involvement early in the decision-making process is likely to be better perceived in Asian countries. Incorporation of palliative care training in the nephrology fellowship curriculum should be considered.

Developing a new model of care for patients with cancer who present to the emergency department: The Mayo Clinic experience.

2014 ◽  
Vol 32 (31_suppl) ◽  
pp. 61-61
Author(s):  
Debra A. Wong ◽  
Tom R. Fitch ◽  
Eric Prommer ◽  
Yu-Hui Chang ◽  
Christopher A. Lipinski
Keyword(s):  
Emergency Department ◽  
Palliative Care ◽  
Supportive Care ◽  
Cancer Patients ◽  
Advance Care Planning ◽  
Emergency Department Visits ◽  
Cancer Type ◽  
Care Planning ◽  
Patients With Cancer ◽  
Advance Care

61 Background: Patients with cancer often have complex symptoms and morbidity that prompt frequent Emergency Department visits. The length of stay in the ED for cancer patients exceeds that of patients without cancer. Patients with cancer are also more likely to be admitted, but are often discharged within 72h. Protracted ED visits, extensive investigations, and the burdens of even a short admission may be distressing and may not be aligned with patients’ care goals and preferences. Furthermore, the healthcare resources dedicated to these patients is considerable and has economic implications. We recently established a Supportive Care Infusion Center (SCIC), an on-campus outpatient unit where patients can receive treatments for symptom relief and comfort; they are assured integrated palliative care with routine oncologic care. We believe there is a subset of cancer patients who can be safely transferred from the ED to the SCIC for appropriate care. Methods: We are retrospectively evaluating cancer patients admitted through the ED to validate clinical parameters likely to lead to admission, and also identify any differences between patients admitted for <72h vs >72h. Patients are analyzed based on symptoms, cancer type, prior cancer therapies, performance status, comorbidities, and presence/absence of advance care planning as well as previous contact with Palliative Care. Data are also being gathered on patient outcomes, including mortality within 60d of admission. Results: Previously established indicators predictive of admission included shortness of breath and SIRS criteria, which our current review validates. We also observe that patients admitted for >72h have greater symptom burden and comorbidities and have received multiple lines of therapy. They also less frequently have advance care planning in place. Data analysis is ongoing. Conclusions: There exists a difference between cancer patients admitted >72h and those discharged within 72h. Awareness of these characteristics may lead to improved workflow in the ED. Identifying patients who may be suitable for transfer to an outpatient supportive care unit rather than short-term admission will also facilitate cost-effectiveness. Future direction includes evaluation of outcomes such as mortality, quality of life, and patient-caregiver satisfaction.

Demenz aus palliativmedizinischer Perspektive: warum ein krankheitsspezifisches Advance Care Planning wichtig ist

2018 ◽  
Vol 75 (2) ◽  
pp. 105-111 ◽  
Author(s):  
Ralf J. Jox ◽  
Francesca Bosisio ◽  
Eve Rubli Truchard
Keyword(s):  
Palliative Care ◽  
Advance Care Planning ◽  
Care Planning ◽  
Advance Care ◽  
Menschen Mit Demenz

Zusammenfassung. Die Palliative Care muss sich im Zuge des demographischen Wandels vieler Gesellschaften rund um den Globus tiefgreifend wandeln. Sie muss mehr und mehr mit der Geriatrie zusammenarbeiten und geriatrische Expertise integrieren. Eine der zentralen Herausforderungen Geriatrischer Palliative Care ist die ethisch angemessene Therapieentscheidung für Menschen, die nicht mehr urteilsfähig sind. Nachdem der bisherige Ansatz herkömmlicher Patientenverfügungen erwiesenermassen enttäuscht hat, wird aktuell, gerade auch in deutschsprachigen Ländern, das systemische Konzept des Advance Care Planning (ACP) verfolgt. In diesem Artikel wird zunächst ACP mit seinen Zielen, Elementen und Effekten vorgestellt. Sodann wird gezeigt, weshalb es für Menschen mit Demenz eines adaptierten ACP-Programms bedarf und was ein solches demenzspezifisches ACP beinhalten muss.

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