Care Beyond Cure
Care Beyond Cure
- Hospice of Marion County, Ocala, FL
- Center for Comprehensive Palliative Care, Ocala, FL
- Hospice of Marion County, Ocala, FL
Please note that all data below was derived from the collaboration's nomination for the Collaboration Prize. None of the submitted data were independently verified for accuracy.
During a 2006 conference, our Chief Medical Officer, Dr. Segismundo Pares learned that 80% of hospital patients could benefit from palliative treatment, whether terminal or not. In an instant, he determined to change that statistic...at least in Marion County.
Dr. Pares envisioned a joint program with the hospital to provide a consulting service that would serve patients hospital-wide. With the full support of both the hospital and hospice, he pulled a team from both entities to attend a workshop at the Palliative Care Leadership Center to study a hospital/hospice program that most closely resembled the situation in Ocala. Within weeks of their return, The Center for Comprehensive Palliative Care, a separate legal company, was formed by Hospice of Marion County, Inc. to provide consulting services to the hospitals.
Munroe Regional Medical Center (MRMC) and The Center for Comprehensive Palliative Care (CCPC) created an innovative partnership, Care Beyond Cure, to provide palliative care through consultative services in a multidisciplinary approach for patients who suffer from life-limiting illness. Together, team members at the hospital and the consulting service provide nationally recognized holistic care that is patient-centered and family-focused. The needs of this patient population had been underserved prior to 2006, when Dr. Pares piloted the program in the hospital setting and was met with immediate success in terms of relief for patients and collaboration with physicians.
The Center for Comprehensive Palliative Care is owned and operated by Hospice of Marion County, Inc., which has a contractual agreement to provide services to Munroe Regional Medical Center. The program is overseen by the Chief Medical Officer; managed by a seasoned GNP (Geriatric Nurse Practitioner), a 2nd ARNP (Advanced Registered Nurse Practitioner) for consults and a team facilitator. In cooperation with MRMC, the Chief of Nursing and a specialized team of palliative trained nurses oversee care and seek referrals for patients who could benefit from the consulting service.
Initially, there was a significant deficit in knowledge among many physicians about the difference between palliative care versus hospice care. Today there is a far better physician comprehension and their supportive acceptance of the palliative program. Today, both physician and nursing no longer focused solely on the “cure” component of healthcare, but through screening tools on every round and continued education, they are keyed also into the important palliative elements of “care” and “comfort.”
An underlying goal of the MRMC/CCPC collaboration is the continuing education of physicians, hospital staff, palliative care teams and the general public of the emerging role of palliative care as mainstream medicine, available to anyone needlessly suffering from unrelieved pain or symptoms. Their expertise targets quality of life issues, comfort care and symptom management via an integrated multidisciplinary team with the goal of relieving physical, emotional, and spiritual or psychosocial pain.
A practical tool for palliative care performance measurement and feedback focuses on prevention and relief of suffering, improving communication, promoting concordance between treatment and individual preferences, and facilitating transitions across care settings. This tool identifies patient preferences and decision-making surrogates, communication between clinicians and patients/families, social and spiritual support, and pain assessment and management. Because quality of care can be evaluated on the basis of structure, process or outcome, the tool is devised to measure quality as a grouping of processes.
Recently, we conducted our annual Physician Satisfaction survey which concluded that our “one service” palliative care is most beneficial, not only to the hospitals, but to the patients and families as well. Since January of this year, CCPC has administered 518 patient consultations with 50% resulting into referrals to Hospice of Marion County. Out of the 591 referrals to CCPC over 47% were received from MRMC.
Prestigious recognition of our program has brought much deserved attention. When CCPC’s medical director, Dr. Pares, was awarded the first Barbara Janosko Leadership Award by the Florida Hospices and Palliative Care Organization, our program was selected as a model for all of Florida. The award was based on his innovation and dedication to providing care in the hospital setting to this underserved patient population. In 2008, the Florida Hospital Association named him a Hospital Hero for his initiation of palliative care for hospital patients. In 2009, the program was one of only nine programs and the only consulting service to receive the prestigious National Consensus Project award, and was presented at the National Hospice and Palliative Care Leadership Conference in Washington, DC. The program took top honors over 40 others competing in the same category, again making our program an example of excellence.
The success of the palliative program in just three years has earned both state and national recognition as a model palliative care program and an example of leadership.
This program is a model for others to replicate. The team presented education to local state representatives about advanced directives, including the POLST (physician orders for life-sustaining treatment), which we propose be legislated into law. As part of this effort, we invited a group of Jacksonville providers here to learn first-hand how we provide palliative care. Other efforts include networking through state and national groups to share expertise and ensure quality palliative care is available to all who need it.
Care Beyond Cure, a joint collaboration between Munroe Regional Medical Center (MRMC) and Hospice of Marion County (HMC), is overseen by a Medical Director and managed by an Advanced Registered Nurse Practitioner (ARNP); a second ARNP was recently added to meet the growing demand for consultations. All three provide one-on-one consults in the hospital with patients and their families, making treatment recommendation for pain and symptom control to the patient’s physician. The office facilitator intakes referrals, assigns consults, compiles consultation data and arranges follow-up visits. A shared data system allows staff from both MRMC and CCPC (The Center for Comprehensive Palliative Care) to access and track information for monthly reporting.
Recent survey results indicate a high level of satisfaction among professional staff as indicated below in the key findings from the following respondents:
ICU Nurses Physicians Social Workers Other Rounding Nurses
86% 10% 1% 2% 1%
Poor Fair Good Very good Excellent
Response time 8% 38% 54%
Communication with team 6% 35% 58%
Helpfulness of recommendations 25% 69%
Benefit of palliative care 18% 79%
Palliative care expertise and satisfaction are directly linked to a philanthropic gift of $118,000 from the MRMC Foundation to renovate a special unit with four dedicated palliative care beds. This unit features a homier atmosphere with carpeted hallways, upscale furniture and a family gathering room.
Program sustainability is ensured by having an effective top-down as well as a bottom-up communication strategy driven by key stakeholders and a multidisciplinary team. Guided by a written team charter and an educational development plan, the palliative care service continues to multiply every year, with a 57% increase in consults in the last two years (831 consults YTD 2010).
Financial implications are significant in terms of cost-saving for the hospital and appropriate elections to hospice, which provides a higher level of care to eligible patients. The Center to Advance Palliative Care’s calculator tool aids hospitals estimate the total annual savings made possible by palliative care services. In 2009, the total LOS + cost per day saving resulted in $1,037,504 for 377 patients. In 2010 YTD, 458 MRMC patients have received palliative care consults, resulting in an estimated saving of $1,500,000 per annum. The reduction in LOS went from 7.1 days in 2006 to just 2.4 days in 2010. More than 48% of referrals to CCPC are generated by MRMC, the largest and only not-for-profit facility of the four acute care hospitals in Ocala.
From one-on-one meetings with medical and nursing professionals to large community conferences, our seminars have educated thousands of people about the benefits of the palliative care service/MRMC collaboration. Last year alone, the CCPC medical director and ARNP conducted 95 presentations reaching 3,709 people.
Consultations not only help alleviate pain and symptoms, they also prevent unnecessary ER visits and hospital readmissions, resulting in cost savings and less demand on community resources. In 2010 YTD, 380 patients elected hospice care, generating $1.85 million in revenue for Hospice of Marion County, CCPC’s parent company.
In 2006, Segismundo Pares, MD, was startled to learn of the high percentage of hospitalized patients experiencing unrelieved pain, shortness of breath, nausea and vomiting. At that time, the figure was 80% of hospital patients. In researching the possibility of palliative care in the hospital setting, he was determined to bring this service to Marion County, Florida.
At the time, Dr. Pares served on the Board of Directors at the local community not-for-profit hospital, Munroe Regional Medical Center (MRMC). Well-respected in the community and not deterred by challenge, he formulated a plan to develop a collaboration between MRMC and Hospice of Marion County, where he also served as a Medical Director. He single-handedly began consultations on ICU patients to determine the need, which was immediately apparent. Within a few months, he arranged for a team of 20 key leaders from Hospice and MRMC to attend a workshop at the prestigious Palliative Care Leadership Center in Kentucky; the group was the largest and most well organized the center had ever trained. Members included personnel from the various disciplines: physician and nursing, financial, marketing, social work and chaplaincy. Working together from the beginning has provided both the impetus and the stamina that has made the program such a success. Buy-in from both organizations was enthusiastic at the leadership level as all the potential benefits were outlined. The planned collaboration provided both the venue and the expertise to offer the palliative care service line to patients in need.
The biggest challenge was to educate and gain acceptance of this innovative collaboration from the medical and nursing staff. Initial reluctance was expected, particularly from some established physicians who were resistant to change. Eventually the immediate relief of patients’ suffering was the lynchpin that won over many early detractors.
Nursing staff received education to determine the difference between hospice and palliative care. Many have gone on to earn Certification in Hospice and Palliative Nursing (CHPN). Since 2006, the CCPC team has been speaking wherever and whenever an opportunity presents itself, reaching some 10,000 people through nursing unit meetings at 6 am and 11 pm, ICU grand rounds, the Ladies of Philanthropy, the Munroe Foundation, new employee orientations, speech therapy, social and case manager meetings, unit clerk meetings, volunteer luncheons, community events, medical expos, local Master Gardeners and Sons of the American Revolution meetings, lawyers and estate planner meetings...to name a few.
The concept of Care Beyond Cure goes beyond the alleviation of pain and suffering. The entire family is involved in all aspects of care, from the initial consult (which can take up to two hours or more) to follow-up treatment options. At all time, the patient and family are encouraged and empowered to make their own health care decisions, along with their physician. The consult covers care preferences; how much suffering a patient is willing to bear, how illness can affect the family, legal, insurance and spiritual issues. One of the first questions asked is: “What are your treatment goals? What do you hope to obtain from treatment?” While palliative care focuses on controlling pain, nausea, shortness of breath and other side effects of illness, it also addresses patients’ concerns about daily living activities and the effect of their illness on other family members. While hospice care is for terminal patients with six months or less to live, palliative care can be provided to any patient at any stage in an illness, regardless of life expectancy.
A driving force behind the success of the collaboration is the alignment of the mission statements of both organizations. MRMC’s Mission is to improve the health of our community by delivering compassionate innovative care through exceptional people doing extraordinary works. CCPC’s complementary mission is to provide the highest quality holistic care to those who suffer from diseases that are life-limiting or life-threatening.
The patient-centered, family-focused care targets quality of life issues, comfort care and symptom management provided by an integrated multidisciplinary team. The goal is to relieve suffering, whether physical, spiritual or psychosocial. Hospital-wide, MRMC has witnessed compassionate innovative care delivered through CCPC, which is now embodied into the hospital culture as a mainstream service line.
As terms of outreach, the Care Beyond Cure team encourages other organizations interested in providing palliative care to make site visits. So far, two hospice groups from Jacksonville, Fl, and others from Lady Lake, Fl, Gainesville, Fl, and Savannah, GA, have visited to learn firsthand how the collaboration operates. The growth of the palliative service is impressive – 70 consults in 2006, 535 in 2007, 651 in 2008, 903 in 2009, and 831 YTD. In its first three years, Care Beyond Cure has earned both state and national recognition as a model palliative care program and an example of cooperative leadership. It was honored with the Barbara Janosko Leadership award from Florida Hospices and Palliative Care and the National Consensus Project award, presented at the annual National Hospice and Palliative Care Organization conference in Washington, DC.
The CCPC team provides consultations to any suffering patient based on needs, not ability to pay. The poverty level in Marion County is astounding—15.6% of the population earns less than $16,244 a year. The current rate of unemployment is 14.6%, well above the national average. Many patients are underinsured or uninsured. Palliative care is not a revenue producer and is consistently in negative financial territory; the YTD deficit is $178,179.00. It is able to continue operation due to the financial backing of Hospice of Marion County. Since January 2010, CCPC has provided 831 consultations with 878 follow-up visits. Approximately 50% of those consultations result in elections to Hospice of Marion County.
This collaboration is a true win-win solution for everyone involved. The hospital’s beds are freed up when patients are discharged to home or a hospice house, patients get out of the hospital faster with a shorter LOS, quality of life is improved and hospice enrolls more patients who might not otherwise have been referred for care.
The palliative service has received positive attention from the local media. Profiles on patients have made engaging feature stories and a significant boost came with the publication of the latest scientific evidence from the three-year study conducted at Massachusetts General Hospital in the August 19, 2010 issue of the New England Journal of Medicine. The research demonstrated the efficacy of palliative care versus treatment alone for patients with the most aggressive form of lung cancer. This data led to a full page newspaper editorial, Palliative Care Gets its Due: Live Longer, Live Better, in September proving that palliative care patients experience:
• Less depression/worry
• less pain
• less nausea
• better mobility
• happier outlook
Future plans include a brick-and-mortar Palliative Care Clinic. The facility would not only provide convenient follow-up care for patients, but would also give palliative care a public image to further increase awareness. A current cost-efficient scenario is to position the clinic in existing space at MRMC in a street-side façade adjacent to the Emergency Department.
The success of the collaboration between MRMC and CCPC is measured in the increasing numbers of patients served each year, the increasing numbers of physicians, nurses and members of the community who are educated about the benefits of palliative care, and the numbers of providers, patients and families who are extremely satisfied with the services. The collaboration between MRMC and CCPC is worthy of the Collaboration Prize because it best demonstrates how like-minded empathetic professionals can create a service that directly meets the needs of the community. This collaboration also identifies how to address the void in caring for an aging population and those with medical conditions that impact quality of life. When there are no other medical alternatives or cure, compassionate care helps ensure optimal patient comfort.