Promoting Excellence : Sustaining, Exporting & Elevating Grantee Innovations : Pathways of Caring

Name of Project: Critical Pathways for Poor-Prognosis Conditions: The VA Center for Patient-Focused Care (“Pathways of Caring”)

Institution: Department of Veteran’s Affairs, West Los Angeles Medical Center, Los Angeles, CA

PI: Kenneth Rosenfeld, MD

Abstract (as described by Project staff)
Pathways of Caring focuses on the development and implementation of critical pathways for three poor prognosis conditions (inoperable lung cancer, end-stage COPD and end-stage CHF) with the goals of establishing processes of care that encourage patient education, informed goal-setting, continuity patient-provider relationships and comprehensive service delivery throughout patients’ disease course. A system of case management coordinates the delivery of comprehensive, multidisciplinary clinical and support services across inpatient, outpatient, home and hospice settings to ensure consistency to patient’s goals.

The core of our patient care service delivery is our case management component. The case manager is directly involved in the assessment of patients needs (be they medical, social, spiritual, etc.) and the facilitation, coordination and delivery of services to address those needs. Basic services provided are telephonic monitoring, symptom management, nutrition, psychology, pastoral, social work, advance care planning and hospice.

Brief Synopsis of Program Characteristics, Successes and Challenges
The project staff, under the direction of Ken Rosenfeld, MD, has created “Pathways of Caring” in an extremely difficult environment: an under-resourced VA system. During the lifespan of this grant, the West Los Angeles VA has experienced elements of institutional chaos, with multiple changes in institutional leadership and loss of critical staff, including early champions of the project. Despite this rampant organizational disruption, the team made significant programmatic and educational inroads.

While case management is at the heart of this model, there are inherent challenges when coordinating care within the VA. There are multiple providers and multiple venues of care; many patients enter the system without a primary care physician (Dr. Rosenfeld then assumes this role); and the social and psychological needs of the majority of patients are complicated and time consuming. Currently one case manager coordinates care for approximately 50-60 patients; staff report that having only one case manager for that size caseload is problematic, particularly without backup coverage.

In addition to care coordination, the project focuses on education, both for patients and professionals. The project’s philosophy is to educate patients about their disease and their options, and has designed materials that involve the patient in goal setting. Professional education has thus far included a variety of optional lectures and discussions by Dr. Rosenfeld (morning case conferences, grand rounds and bedside teaching) to educate attending physicians and physicians-in-training. Of note, Dr. Rosenfeld recently received approval to launch a palliative care training program for generalists where physicians will be incentivized to take the board certification prep course by receiving additional salary for filling a “scarce specialty need.”

The VA has a sophisticated electronic medical records system that this project is utilizing: Staff enters prominently displayed computerized notes concerning patient’s preferences and goals of care; this information then is available to any VA member with access to the patient’s electronic medical record.

Exportable Products/Tools
The project team developed:

Communications
The project itself does not have a website. However, www.va.gov/OAA/flp/default.asp shows the VA’s efforts to integrate palliative care into their system, including information on their new fellowship program. The page also includes presentations by Dr. Rosenfeld.

Internal Sustainability
The prospect appears quite good for this project to not only be sustained but to also expand within the West Los Angeles VA system. This effort is aided by Dr. Rosenfeld’s selection as a PDIA Faculty Scholar, providing him with salary to support the institutionalization of the project started with RWJF funds.

Pathways of Caring staff recognized that for the project to be fully integrated, case management would need to be widely adopted into the institutional delivery system. To that end, Dr. Rosenfeld submitted a proposal--that the administration appears to have accepted-- for a three-phase expansion of the project, beginning with the addition of 5-6 case managers in ’01.

Project staff feels that in addition to the expanded case management services, the following are necessary ingredients for “Pathways of Caring’s” sustainability:

Generalizing the Model
Project staff has created a model that may well have applicability to the VA in general, with the VA’s growing interest in end of life care. In a recent phone conversation, Dr. Rosenfeld said the VA has decided to institute six palliative care fellowship sites and West LA VA was selected as one of the six.

With financial support from the NPO’s communications funds (matched by funds from the VA nationally), Dr. Rosenfeld is hosting a summit for VA medical centers involving leaders of palliative care programs at VA facilities around the country. This summit, to be held in Fall ’01 on the day prior to CAPC’s Fall Forum, will help disseminate the Pathways of Caring model to key innovators and enable clinician-researchers and administrators to discuss common operational challenges and share creative strategic approaches to those challenges.

Project staff feels that more data about their project needs to be gathered and analyzed, particularly regarding its fiscal aspects. Now that their model has been built, it needs to be tested, to determine how feasibly it can be exported to other VA sites.

When project staff was asked, “What will it take to generalize what you have learned?” they replied: