Filling the Gap: Creating an Outpatient Palliative Care Program in Your Institution

Well-designed, randomized trials demonstrate that outpatient palliative care improves symptom burden and quality of life (QOL) while it reduces unnecessary health care use in patients with cancer. Despite the strong evidence of benefit and ASCO recommendations, implementation of outpatient palliative care, especially in community oncology settings, faces considerable hurdles. This article, which is based on published literature and expert opinion, presents practical strategies to help oncologists make a strong clinical and fiscal case for outpatient palliative care. This article outlines key considerations for how to build an outpatient palliative care program in an institution by (1) defining the scope and benefits; (2) identifying strategies to overcome common barriers to integration of outpatient palliative care into cancer care; (3) outlining a business case; (4) describing successful models of outpatient palliative care; and (5) examining important factors in design and operation of a palliative care clinic. The advantages and disadvantages of different delivery models (e.g., embedded vs. independent) and different methods of referral (triggered vs. physician discretion) are reviewed. Strategies to make the case for outpatient palliative care that align with institutional values and/or are supported by local institutional data on cost savings are included.

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Integrating contemplative and spiritual care in outpatient palliative care: A pilot study.

Journal of Clinical Oncology ◽

10.1200/jco.2016.34.26_suppl.247 ◽

2016 ◽

Vol 34 (26_suppl) ◽

pp. 247-247

Author(s):

Craig D Blinderman ◽

Alex Beth Schapiro

Keyword(s):

Palliative Care ◽

Spiritual Care ◽

Descriptive Analysis ◽

Care Program ◽

Well Being ◽

Comprehensive Cancer Center ◽

Cancer Center ◽

Pilot Program ◽

Palliative Care Program ◽

Care Clinic

247 Background: Spiritual support is associated with better outcomes in cancer care and at the end of life (1, 2). Consensus guidelines advocate for incorporating spiritual care in the provision of specialist level palliative care (3). Contemplative care practices and chaplaincy interventions have the potential for mitigating existential distress, cultivating prognostic awareness, and fostering spiritual approaches to grieving and coping with advanced cancer. We present the results of a pilot program demonstrating the feasibility and impact of integrating a contemplative care chaplain in an outpatient palliative care program in a culturally diverse patient population in a large, academic cancer center. Methods: Case series and descriptive analysis. A description of 10 cases seen by a contemplative care chaplain in our outpatient palliative care clinic in the Herbert Irving Comprehensive Cancer Center (HICCC) at Columbia University will be presented. A descriptive analysis using a chaplaincy-centered model of assessment will highlight the domains of suffering and subjective integration of psychosocial and spiritual concepts. Results: Patients were generally in favor of meeting with and sharing their feelings openly with the chaplain. Patients’ describe important domains pertinent to their well being: meaning, family integration, spiritual practices, existential concerns, prognostic awareness. Subjective transformation and integration of the following constructs: “healing,” “gratitude,” “anger,” “hope,” “fear” were possible with only a few patient encounters. None of the patients were opposed to an initial visit and assessment. In only one case, the family requested not having further visits due to strong emotional reactions that came up. Conclusions: Preliminary results from a novel, pilot program integrating contemplative and spiritual care in an outpatient palliative care program suggest that it is a feasible intervention and should be considered in other cancer centers. Further studies will need to qualify and quantify the additional value and impact of spiritual care integrated in ambulatory palliative care services.

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Palliative care impact on symptom burden.

Journal of Clinical Oncology ◽

10.1200/jco.2019.37.27_suppl.217 ◽

2019 ◽

Vol 37 (27_suppl) ◽

pp. 217-217

Author(s):

Kathleen Dunn ◽

Morgan Hannaford ◽

Scott Hartman ◽

Diane Denny, DBA ◽

Timothy Holder MD

Keyword(s):

Palliative Care ◽

Group Versus ◽

Symptom Burden ◽

Care Program ◽

Disease Stage ◽

Initial Assessment ◽

Cancer Type ◽

Palliative Care Program ◽

Patient Reported ◽

The Impact

217 Background: A national network of five hospitals piloted the use of a patient reported outcomes tool as a means for referring patients to the palliative care program. An externally validated assessment tool that captures patients’ perceived symptom burden from baseline and every 21 days was used as means of identifying patients who might benefit from referral if they met the following criteria: six or > symptoms from 27 increasing in severity by two points or > since their last assessment and determined as having any stage cancer with metastatic disease, stage 3 not in remission, or stage 4 and not already enrolled in palliative care. The data generated from the pre and post referral assessments to the palliative care program was then used to measure the impact of the program on symptom burden for this group versus those patients referred to palliative care but electing not to engage. Methods: The patient population, identified as patients who took the assessment during a selected three-month period, was reviewed to identify two groups: those who were referred through the SIT process and subsequently joined the palliative care program, and those who were referred to palliative care but chose not to attend the appointment. Results were then reviewed for both groups for a six-month period, comparing the scores from the patients’ initial assessment and their subsequent assessment. The data from both groups was compared to identify changes in scores by symptom and overall average symptom scores and the cohorts reviewed for similarities and differences (age, gender, cancer type). Results: Out of the 27 symptoms the cohort electing to utilize palliative care had higher pre-referral scores than the comparison group; and their symptoms improved at a rate greater than those not seeking palliative care. The symptoms in which the greatest impact was experienced included: activity, appetite, drowsiness, sense of family, hope, mood, and sexual interest. Conclusions: Interventions from the Palliative Care program had a positive impact on symptom burden in comparison to the group that was referred for services but did not enter the program.

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UT Southwestern’s Palliative Care Program: Measurable Patient Impact and Cost-savings

Journal of Pain & Palliative Care Pharmacotherapy ◽

10.1080/15360288.2019.1624675 ◽

2018 ◽

Vol 32 (4) ◽

pp. 212-215

Author(s):

Ashley Bird ◽

Steven Leach ◽

Stephanie Houck ◽

Kelly Robinson ◽

Tiffany Lawson

Keyword(s):

Palliative Care ◽

Cost Savings ◽

Care Program ◽

Palliative Care Program

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Commentary: Is there a model for demonstrating a beneficial financial impact of initiating a palliative care program by an existing hospice program?

Palliative & Supportive Care ◽

10.1017/s1478951504040568 ◽

2004 ◽

Vol 2 (4) ◽

pp. 419-423 ◽

Cited By ~ 5

Author(s):

STEVEN D. PASSIK ◽

CAROL RUGGLES ◽

GRETCHEN BROWN ◽

JANET SNAPP ◽

SUSAN SWINFORD ◽

...

Keyword(s):

Palliative Care ◽

Medical Center ◽

Academic Medical Center ◽

Cost Savings ◽

Care Program ◽

Palliative Care Program ◽

Potential Cost ◽

Physician Visits ◽

Financial Benefits ◽

Simple Models

The value of integrating palliative with curative modes of care earlier in the course of disease for people with life threatening illnesses is well recognized. Whereas the now outdated model of waiting for people to be actively dying before initiating palliative care has been clearly discredited on clinical grounds, how a better integration of modes of care can be achieved, financed and sustained is an ongoing challenge for the health care system in general as well as for specific institutions. When the initiative comes from a hospital or academic medical center, which may, for example, begin a palliative care consultation service, financial benefits have been well documented. These palliative care services survive mainly by tracking cost savings that can be realized in a number of ways around a medical center. We tried to pilot 3 simple models of potential cost savings afforded to hospice by initiating a palliative care program. We found that simple models cannot capture this benefit (if it in fact exists). By adding palliative care, hospice, while no doubt improving and streamlining care, is also taking on more complex patients (higher drug costs, shorter length of stay, more outpatient, emergency room and physician visits). Indeed, the hospice was absorbing the losses associated with having the palliative care program. We suggest that an avenue for future exploration is whether partnering between hospitals and hospice programs can defray some of the costs incurred by the palliative care program (that might otherwise be passed on to hospice) in anticipation of cost savings. We end with a series of questions: Are there financial benefits? Can they be modeled and quantified? Is this a dilemma for hospice programs wanting to improve the quality of care but who are not able on their own to finance it?

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