At the conclusion of this project, eight patients received palliative care referrals, but only two have been scheduled in the program or are currently awaiting scheduling. This project did not achieve its goal of increasing enrollment by 50%. Patient and provider fears about end of life, addition of care providers, and inconvenience were identified as the main barriers to
obtaining more palliative care referrals. The large scale and complicated follow-up requirements of this project suggest that future aims to improve palliative care enrollment should be explored. This could be accomplished by broadening the project to include any palliative care program rather than one specific clinic or by partnering between PCP offices and one palliative care clinic to develop relationships. Regardless of the method, efforts should be made to improve both patient and provider education to overcome the fears and biases associated with palliative care.
APPENDIX A: PALLIATIVE CARE ELIGIBILITY SCORING SYSTEM 1) Physical domain/Serious Illness
More than 1 point can be earned in this domain if pt qualifies for multiple criteria
a. Cancer (metastatic or hematologic) b. Renal failure, end stage
c. Advanced Dementia
d. Advanced liver disease or cirrhosis
e. Diabetes with severe complications – i.e. ischemic heart disease, peripheral vascular disease, renal disease, or complications leading to a hospitalization. f. Amyotrophic lateral sclerosis (ALS)
g. Acquired Immune Deficiency Syndrome with CD 4 count < 100
h. Hip fracture with advanced dementia or other significant neurodegenerative condition (progressive MS)
i. Chronic obstructive pulmonary disease or interstitial lung disease - only if using home oxygen or hospitalized for the condition
j. Congestive heart failure - only if hospitalized for the condition
2) Utilization (look at ER visits and hospital stays, including Care Everywhere) More than 1 point can be earned in this domain if pt qualifies for multiple criteria
a. 30-day readmission in last 6 months
b. 3 unplanned hospitalizations (admissions and readmissions) c. > 3 ER visits in the past 6 months
d. Hospitalization longer than 2 weeks 3) Age:
Up to 2 points can be earned
a. Age > 75: 1 point b. Age >85: 2 points 4) Functional domain:
Binary domain: Only 1 point can be earned if any of the following present:
a. Fall within the last 6 months
b. Durable medical equipment ordered (See Look at last Case Manager note titled “Final Transition Planning Assessment” and look at the Home Care/ Home Medical Equipment needed at discharge? Section)
c. Receiving assistance with any of the basic activities of daily living (ADL): – eating – bathing – dressing – toileting – transferring – walking
5) Existing Advance Care Planning
Binary Domain: only 1 point can be earned if any of the following present:
a. No documented ACP note in EHR
6) Psychosocial support
Binary domain, only 1 point can be earned.
a. Award 1 point for concern for lack of psychosocial support (Financial strain, Lack of transportation etc)
7) Symptoms:
Binary domain, only 1 point can be earned.
a. uncontrolled symptoms (pain/depression/fatigue/weight loss/dyspnea/nausea) Exclusion Criteria
- Serious mental illness, personality disorder or substance abuse as primary diagnosis - Non-compliance as primary driver
Calculate Total points ____
If greater than or equal to 5 – Automatic Referral If 3 or 4 – Clinician reviews
APPENDIX B: EMAIL TO PRIMARY CARE PROVIDERS Dear SAMPLE:
I am a registered nurse and Doctor of Nursing Practice student at UNC and I am working to help identify patients who may benefit from palliative care consultation. It looks like (patient’s name) may benefit given (eligibility description). Many patients do not realize that palliative care is not the same as hospice and can be used at any stage of disease, with or without aggressive
treatment. Please let us know your thoughts and feel free to call my cell phone at XXX-XXX- XXXX if I can be helpful with anything. Below is information about the clinic.
The Palliative Care Clinic at the Ambulatory Care Center is a consultative outpatient clinic that can help to assess symptoms, address support needs of patients and families, promote advance care planning and align decision-making with goals of care all in collaboration with you. The clinic is located at [clinic location].
If you agree that a palliative care consultation would benefit your patient, please discuss the referral with your patient and place a referral in Epic- “Ambulatory Referral to Palliative Care”. A discussion about referral has been shown to be more beneficial coming from the primary provider than someone less familiar with the patient. However, if you are unable to discuss with the patient, I would be happy to contact them and speak with them about the palliative care clinic. If you do not feel your patient is appropriate for palliative care as this time, please respond to this message in the next 5 business days.
Feel free to contact me directly with any questions or concerns. Thank you, and we look forward to working with you.
43
APPENDIX C: DATA COLLECTION SPREADSHEET
Today's date
(manual entry): 10/8/2019
Status Initial Contact Status date Expiration date Expired status Time to enrollmentMedical Record
Number Patient Name PCP Comments
At SNF or hospitalized 10/8/2019 10/15/2019 Ok XXXXX XXXXX XXXXX XXXXX
Clinician declined 9/30/2019 9/30/2019 10/7/2019 declined XXXXX XXXXX XXXXX XXXXX
Patient declined 9/30/2019 10/8/2019 10/15/2019 declined XXXXX XXXXX XXXXX XXXXX
Email sent 9/30/2019 10/8/2019 10/15/2019 Ok XXXXX XXXXX XXXXX XXXXX
MD phone call 1 9/30/2019 10/8/2019 10/15/2019 Ok XXXXX XXXXX XXXXX XXXXX
Patient phone call 2 9/30/2019 9/30/2019 10/7/2019 needs action XXXXX XXXXX XXXXX XXXXX
Enrolled 9/30/2019 10/8/2019 10/15/2019 enrolled XXXXX XXXXX XXXXX XXXXX
Deceased or enrolled in hospice 9/30/2019 10/7/2019 deceased/hospice XXXXX XXXXX XXXXX XXXXX
Deemed not eligible 9/30/2019 10/7/2019 not eligible XXXXX XXXXX XXXXX XXXXX
Unable to contact 9/30/2019 10/7/2019 unable to contact XXXXX XXXXX XXXXX XXXXX
APPENDIX D: DEMOGRAPHICS Demographics
All Eligible Patients* (n=) Percent
Male 30 60 Female 20 40 White 38 76 Black 10 20 Asian 1 2 Hispanic 1 2 Other 0 0
Age Range 59-97 years
Average Age 84.4 years
Number of Chronic Conditions
0-2 Chronic Conditions 2 4 3 Chronic Conditions 4 8 4 Chronic Conditions 4 8 5 Chronic Conditions 6 12 6 Chronic Conditions 9 18 7 Chronic Conditions 6 12 8 Chronic Conditions 8 16 9 Chronic Conditions 9 18 10 Chronic Conditions 2 4
Common Chronic Condition Prevalence
Anemia 13 26
Arthritis 11 22
Cancer 14 28
Chronic obstructive pulmonary disease 10 20
Other respiratory disease 14 28
Congestive heart failure 24 48
Hypertension 43 86
Other heart disease 32 64
Neurological or cognitive disease 19 38
Diabetes 16 32 Gastroesophageal reflux 11 22 Hyperlipidemia 20 40 Kidney disease 28 56 Stroke 11 22 At SNF/Hospitalized Male 1 12.5 Female 7 87.5 White 5 62.5 Black 2 25 Asian 1 12.5 Hispanic 0 0
Demographics
All Eligible Patients* (n=) Percent
Average Age 82.12 years
Average Number of Chronic Conditions 7.25 Already Enrolled Male 3 60 Female 2 40 White 4 80 Black 1 20 Asian 0 0 Hispanic 0 0
Age Range 77-95 years
Average Age 83.8 years
Average Number of Chronic Conditions 5.6 Clinician Declined Male 5 62.5 Female 3 37.5 White 7 87.5 Black 1 12.5 Asian 0 0 Hispanic 0 0
Age Range 77-95 years
Average Age 87.88 years
Average Number of Chronic Conditions 6.5 Patient Declined Male 6 40 Female 9 60 White 12 80 Black 2 13.33 Asian 0 0 Hispanic 1 6.67
Age Range 71-97 years
Average Age 84.6 years
Average Number of Chronic Conditions 6.8 Referred to Palliative Care
Male 3 37.5 Female 5 62.5 White 6 75 Black 2 25 Asian 0 0 Hispanic 0 0
Age Range 66-96 years
Average Age 82.38 years
Average Number of Chronic Conditions 7.13 Unable to Contact
Demographics
All Eligible Patients* (n=) Percent
Female 4 66.67
White 4 66.67
Black 2 33.33
Asian 0 0
Hispanic 0 0
Age Range 78-90 years
Average Age 85.5 years
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