TriCentral PC Toolkit : Chapter 1: Introducing the TriCentral Palliative Care Program : TriCentral's Palliative Care Program

TriCentral's Palliative Care (TCPC) Program was launched first as a pilot project in 1997 and then as a formal program in 1998 as a means of achieving balance in end-of-life care and helping seriously ill patients find peace and dignity between the extremes of too little care and too much. The program was initiated as an alternative to KP's hospice program, which like other hospice programs across the country, was being underused. At TriCentral, average survival time for hospice patients was 48 days from the time of enrollment. Twenty-six percent of these patients died within the first seven days of admission to the program; another 35 percent died in the remainder of the first month. Many KP patients eligible for hospice care either refused services or were never referred to the program for a variety of reasons, including physician uncertainty in determining life expectancy, patient unwillingness to forego curative care (and hope), and other negative connotations of the word "hospice." As a result, patients often died in acute-care hospital beds or intensive care units, sometimes following bouts of medically futile care. In 1996 at TriCentral, 63% of the patients who died in the intensive care unit and 54% of those who died in acute medical beds had a primary or secondary diagnosis of one of three commonly fatal, incurable conditions: cancer, congestive heart failure (CHF), or chronic obstructive pulmonary disease (COPD).

Frustrated and disturbed by these trends, we established the Palliative Care (PC) program, an outpatient service housed in our Home Health Department that offers improved care to dying patients and their families. Modeled after KP's hospice program in that it offers superb pain management and other comfort care in the patient's home, the PC Program features three important modifications, all of them intended to promote timely referrals to the program:

• Physicians are not required to give a six-month prognosis. Recognizing that it is often difficult to estimate life expectancy, we relaxed referral guidelines. Physicians are asked to refer any patient if they "would not be surprised if this patient died in the next year." Thus, as a general rule, palliative care patients are accepted into the program with a prognosis of 12 months or less to live.
• While the Palliative Care Program emphasizes much improved pain control and other symptom management, patients do not have to forego curative care, as they do in hospice programs.
• Patients are assigned a palliative care physician who coordinates care from a variety of healthcare providers, including specialists and the patients' primary care physician, thus preventing the service fragmentation that often occurs in healthcare systems.

In addition to these design improvements, the program features five core components, each of which contributes to enhanced quality of care and patient quality of life. These core components are:

• An interdisciplinary team approach, focusing on the patient and family, with care provided by a core team consisting of a physician, nurse, and social worker, all with expertise in pain control, other symptom management, and psychosocial intervention.
• Home visits by all team members, including physicians, to provide medical care, support, and education as needed by patients and their caregivers.
• Ongoing care management to fill gaps in care and ensure that the patient's medical, social, and spiritual needs are being met.
• Telephone support via a toll-free number and after-hours home visits available 24 hours a day, seven days a week as needed by the patient.
• Advanced care planning that empowers patients and their families to make informed decisions and choices about end-of-life care.

A recent external evaluation established that the TCPC Program met the complex physical, emotional, social, and spiritual needs of chronically ill patients at the end of life while improving the cost effectiveness of such care. The evaluation, which compared 145 palliative care patients to a matched sample of 151 home-health KP patients, showed that the palliative care patients had comparatively fewer emergency department visits, inpatient days, skilled nursing days, and physician office visits (p<.0001), although they had more home care visits. When all service costs—for both inpatient and outpatient care—were considered, total average costs for TCPC patients were 45% lower than costs for the comparison group.

While dollar signs are important at a time when healthcare costs are spiraling upward, policy makers, medical experts, and patient advocates agree that the push to improve care at the end of life centers around more than a question of money. It's also a question of personal values: Are the individual's preferences for care and treatment at the end of life being met? Here, as well, the TCPC Program has been successful. While improving the cost-effectiveness of care, the program has not sacrificed quality of care. Patient satisfaction and quality of life indicators, which were measured 60 days following patient enrollment, were significantly higher among TCPC patients than the comparison group, even though palliative care patients used significantly fewer in-patient services.

These results reflect what palliative care experts have observed again and again: that in the end, what matters most is not necessarily more treatment, but rather quality of treatment. As another indicator of success, patient referrals have increased every year since the program's inception. Today, the program's average daily census is more than 80-90 patients.

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