Promoting Excellence : Sustaining, Exporting & Elevating Grantee Innovations : Improving End-of-Life Care

Name of Project: Improving End-of-Life Care: Integrating Community Case Management and Palliative Care

Institution: Mt. Sinai School of Medicine and Franklin Health, Inc., New York, NY

PI: Diane Meier, MD and William Thar, MD

Abstract (as described by Project staff)
Mount Sinai School of Medicine in New York is partnering with Franklin Health, Inc., a community-based complex case management organization, and Blue Cross/Blue Shield of South Carolina, to coordinate consistent, high-quality care for seriously ill, community-dwelling patients. The project integrates advance care planning and symptom management for high-risk patients who have life-limiting illnesses and may be homebound or employed. The project will evaluate the feasibility and benefit of formal palliative care assessment and feedback to physicians in the context of community-based complex case management. Patients who have received the intervention will be compared to Franklin Health patients who did not have the intervention to evaluate the intervention's effectiveness in the areas of patient centered outcomes, provider outcomes and utilization of medical resources.

Brief Synopsis of Program Characteristics, Successes and Challenges
In this unique three way (and three state!) collaboration, project staff at Mt. Sinai provides palliative care expertise (through training, protocol development and ongoing consultation) to Franklin Health (FHI) case management nurses contracted to see select patients enrolled in Blue Cross/Blue Shield of South Carolina and Companion HealthCare of South Carolina’s commercial insurance plan. The project focuses on younger commercially insured patients. This is an “upstream” population of very sick people, averaging 46 years of age, generally suffering from serious, progressive, and life threatening illnesses, who will likely consume high dollar amounts of resources and, therefore, could likely benefit from the sophisticated Franklin case management program.

Unlike the patients participating in many of the Promoting Excellence in End-of-Life Care projects, the patients in the Mt. Sinai-Franklin project generally do not see themselves as dying. Accordingly, some of the original basic tenets of the project shifted away from aspects addressing quality of care and quality of life at the end of life. For example, project staff found it challenging to use the Missoula-Vitas Quality of Life tool on patients who do not view themselves as terminal and discontinued use of the tool. They also struggled with what to include in the palliative care training for the case managers and ultimately did include end-of-life issues.

Part of the success of this project can be attributed to strength of the leadership and support that has been provided by the three partnering organizations: At Mt Sinai, the project is housed at the Lilian and Benjamin Hertzberg Palliative Care Institute, with project direction provided by Diane Meier, MD and Sean Morrison, MD. Franklin Health, a stellar for-profit, complex case management corporation, brings to the project not only the case management staff, but also a sophisticated web-based clinical database that has been redesigned to integrate with this project’s clinical protocols. Bill Thar, MD, FHI vice president, serves as co-PI on this project and Tobe Banc, MD, a physician with certification in palliative care, provides medical direction to the FHI case managers. The involvement of BCBS leadership (physicians Ashby Jordan and John Little) is critical to sustaining and exporting the project.

Exportable Products/Tools

• Training modules for case management nurses on palliative care assessment, care plan implementation, and approaches to physician feedback;
• Franklin Health Communication Instrument to assess interest in discussing end-of-life care and appointing a health care agent;
• “A Practical Guide to Communication Skills” – a CD Rom given to nurse case managers; and
• Explicit care pathways or treatment alternatives for each physical symptom and a series of one-page referenced treatment summaries for most common symptoms (faxed to treating physicians to educate and support them in the use of unfamiliar palliative care therapies.

Communications/Dissemination
Mount Sinai’s palliative care program was featured on Bill and Judith Moyer’s “On Our Own Terms.” While this segment did not specifically highlight the work being done through the Promoting Excellence grant project, it certainly did help disseminate information on Mount Sinai’s approach in general.

Internal Sustainability
Staff responded to the question “What will it take to sustain what you have learned,” with:

• Develop practical and more flexible implementation of study instruments and study protocols to meet client (industry) guidelines;
• Rollout training in the use of study instruments and study protocols to ALL Franklin Health teams; and
• Develop more effective training on communicating with treating physicians.

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

• Continued communication between Franklin Health and The Palliative Care Institute at Mount Sinai School of Medicine to develop training programs and schedule training seminars;
• Publication of study findings, lectures and networking with other community agencies, other nursing care organizations and leadership, and executives (e.g. American Committee of Health Executives); and
• Implementation of care management programs in client organizations.

Words of Wisdom from the Project
When project staff was asked what advice they would give another organization that wished to establish a similar project, they replied:

• To focus on communications and support for case management nursing staff with physician back-up and on-going training (quarterly) sessions;
• Invite treating MDs in the community to Palliative Care Training Seminars; and
• Work harder to engage and involve treating community physicians.

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Promoting Excellence in End-of-Life Care is a National Program Office of The Robert Wood Johnson Foundation dedicated to long-term changes in health care institutions to substantially improve care for dying persons and their families. Visit PromotingExcellence.org for more resources.