Achieving Structural Homogeneity in Two Diverse Palliative Care Populations

As a 731 licensed-bed facility in a large metropolitan area, our institution frequently receives adult patients with a wide array of complex diseases, trauma, and medical diagnoses. Our facility is also a tertiary referral center for women and infant’s health, signifying that a number of infants with complex medical diagnoses are triaged for treatments that are unavailable in some communities. In 2001, recognition of the patient complexity and illness severity of our hospitalized patients spawned the development of an adult Palliative Care Service (PCS). Initially this was spearheaded by two Registered Nurses and a Physician. Nearly a decade later, recurring themes between numerous families of our neonates were identified. The common themes that evolved were the inability to articulate prognosis, comprehend all available treatment options, and frustration expressed with fragmented care received across healthcare settings. Altogether, these needs spawned the development of our neonatal PC program.

Over the past 13 years, this formerly small service line has endured an extreme metamorphosis, blossoming into a robust program, with 2 distinctly different interdisciplinary teams (IDT) with one cohesive overarching structural umbrella, the PCS. Each team is comprised of the following disciplines: Physician(s), Nurse(s), Social Work(ers), and Chaplain(s). Other elements of the PCS include a 16-bed inpatient PC unit, a nurse manager who oversees both the PCS line and the inpatient PC unit, and a program coordinator. We recently received our first recertification for Advanced Palliative Care from The Joint Commission (TJC). However, it was through our initial designation of this specialty certification that facilitated the structural growth of our well-established adult PC program and our rather newly developed neonatal PCS, weeCARE.

Seemingly counterintuitive, the two distinctly diverse populations served by PCS have morphed into a structurally analogous service line over the preceding two year time period since our initial certification was awarded in 2012. Structural homogeneity was ascertained through more stringent and purposeful implementation of the Clinical Practice Guidelines for Quality Palliative Care (National Consensus Project [NPC] for Quality Palliative Care, 2013). This has led to a number of improvements within our service, from formalizing the structure of our service line, to improving the quality of care provided to patients and families, and most notably to our recent success in achieving our first recertification for Advanced Palliative Care from TJC.

To accomplish a homogenous structure, we were first charged with infiltrating the weeCARE Team, which was led by members of the healthcare team who had become jaded over the years. This fostered a negative environment dismissing a culture of accountability and causing this team to flounder. The PC leadership team, alongside the NICU manager, began attending the weeCARE meetings, which were occurring as frequently as every other week, yet this team was stagnant. A short time passed, and the jaded team members quickly disengaged, leaving a group full of spirit and optimism. Albeit small, the newly energized team quickly began to flourish and within less than a year after this team reformed, the weeCARE Team has consistently remained one that is in high-demand. For the past year, the expertise of the weeCARE Team has been called upon for approximately 25-30% of all the babies in the NICU at any given time.

Another essential element lied in defining and documenting our scope of service. This meant that our patient population must be clearly identified, which could have proven problematic for our neonates because we, ourselves were still trying to identify who these babies were. Because we were unable to clearly articulate this population, we maintained the stance of purposeful ambiguity so that defining the PC population was left to the reader to interpret. Our population was defined as persons with life-limiting, life-threatening, or life-altering diagnoses. Then we needed to define what PCS provides to patients and families of our population. Thoughtful wording was important in defining our services because following the launch of this new PCS in 2001; the purpose was to build a patient population in which to provide such services. Historically, the greenery and naivety of our forefathers who started PCS led the service down a tattered path of the chronic pain management service and the end-of-life care service. There have been great efforts and countless hours spent in educating the more than 3,300 hospital clinical staff and nearly 1,200 hospital privileged physicians within our institution to mend this path. Great strides have been made through our continued efforts and it is with this premise that we gave careful attention to wording when defining what PCS provides. Ultimately, we determined that the needs of our population would encompass elements such as: enhanced communication, clarification of information and choices for treatment, symptom management, advanced care planning, assistance with ethical dilemmas, facilitating healthy coping mechanisms, offering family support and education, ensuring that comfort care is optimized, and maintaining dignity.

Initial certification for Advanced PC was obtained in the latter part of November 2012. Although unsuccessful in receiving our official certification on the day of our site visit, we ultimately became certified within 2 weeks. The requirement for improvement (RFI) and action plan was due to the deficiency within our core interdisciplinary team (IDT). According to the NCP guidelines and to TJC, PC is best provided to patients, and only eligible for certification, when the core IDT is composed of each of the following disciplines: physician, nursing, social work (SW), and chaplain. A collaborative with the care transitions management department, which is responsible for the hospital SW who functions as discharge planners, was in place however; we lacked an integral piece of our adult core IDT, making our service deficient and ultimately cited with an RFI to rectify. After spending the day with our TJC surveyor, an action plan was quickly implemented. Within 2 weeks of implementing our action plan, we officially received our certification letter. In fact, in 2013, our PC SW became incorporated into the PCS department and no longer part of the Care Transitions Department.

Over the following 2 years, we continued to identify the benefits that come with what this scrupulous certification. Not only have we incorporated a dedicated SW to our team, but also have added additional SW team members to our adult arm and continue to have collaboration with the SW department for our neonatal population. Shortly after being awarded this certification, our PC chaplain unexpectedly died, leaving heavy hearts and another void to fill within our team. An attempt to find a hospital staff chaplain dedicated to our PC population was trialed however; our average monthly census approximates 200 patients. An initial in-depth spiritual/religious/existential assessment by a PC chaplain is required by TJC for all PC patients, which proved to be an unfeasible expectation for one person. To accomplish this seemingly insurmountable feat, we sought an alternative approach and broached the subject of partnering with our clinical pastoral education (CPE) department. The CPE directors and the PC leadership team composed an 8-week didactic curriculum differentiating and encompassing specific elements inherent to PC chaplaincy. This didactic was taught by both the CPE directors and the PC leadership teams and this was followed by 8-weeks of case presentations, laying the foundation of our new CPE-PC education model.

Because structural homogeneity was an important feat, electronic medical record (EMR) documentation needed attention. A collaborative effort between the PC coordinator and the IDT members of each discipline quickly ensued. Content development inherent to each core IDT discipline was underway in the development of EMR templates specific to PCS. Concepts specific to the scope of services provided by NPs, Physicians, SWers, and Chaplains, were identified and constructed into an initial consultation assessment and a follow-up note for each respective discipline. Each of the templates was created with elements required by the NCP guidelines. The initial assessment note for SW incorporates an in-depth psychosocial assessment and a follow-up template, which is less comprehensive than the initial assessment, incorporates interventions specific to the function of SW on the IDT. Initial assessments for Chaplains incorporate an initial comprehensive spiritual/religious/existential assessment that also focuses on anticipatory grief. The follow-up note template incorporates interventions specific to PC Chaplaincy, which can differ from interventions specific to hospital Chaplaincy. The initial consult templates for both Physicians and NPs are identical and heavily focus on the symptom assessment and management. The follow-up progress notes are also less comprehensive. Something unique to the construct of each of these templates is the documentation of a family conference or a family meeting that was multidisciplinary. Each of these EMR templates features this section and each team member present for the conference or meeting documents this occurrence but the content may be vastly different from one discipline to the next, highlighting the importance of each role within the composition of the IDT.