Name of Project: The Comprehensive Care Team
Institution: University of California, San Francisco,
General Medicine Practice, San Francisco, CA
PI: Michael W. Rabow, MD
Abstract (as described by Project staff)
The Comprehensive Care Team provides education and support to patients at the beginning of the end of life in order to improve symptom management, psychological and spiritual well being, and satisfaction with care. We offer palliative care consultation to outpatients, as well as their professional and family caretakers, engaged in managing and treating serious congestive heart failure, chronic obstructive pulmonary disease, and cancer.
Brief Synopsis of Program Characteristics, Successes and Challenges
The CCT is directed by a social worker and has depended on primary care physicians for referrals into the program. Financial hardships at UCSF have trickled down to the Department of Medicine and to the Department of General Internal Medicine. The General Medical Practice (GMP) has responded to a nearly $1 million budget deficit with massive reductions in personnel and services. Despite this and because of a committed CCT team, this project has been successful in improving people’s lives. One of the most striking preliminary findings from the feedback received from patients completing their one-year participation with the project is that many of the most deeply appreciated services were those involving simple, human contact. This is more easily understood when one looks at what the project says about itself:
“This project has unearthed and documented incredible unmet need. Once unearthed this unmet need is filled only by a very small CCT team because their system at UCSF is so amazingly overworked that there are not the personnel to respond to patient needs.”
The project was designed to provide primarily consultation and education – it provides care that no other patients in the UCSF General Medical Practice receive. It provides on-going social worker-directed case management, including three formal, comprehensive assessment and counseling sessions over the course of one year, in addition to usual care provided for CHF, COPD and cancer patients. In addition, patients may receive medication counseling by a pharmacist, chaplaincy consultation, facilitated group-support, nurse home visits, and volunteer patient advocate social support. The project, on average, has a caseload of 50 patients, and many are socially and economically disenfranchised. The project has two main pathways for patient identification: primary care physicians are asked to recommend patients meeting inclusion criteria and electronic medical records are queried for lists of patients with index diagnoses. These prospective patient names are suggested to the PCPs.
The project has tried a number of patient interventions including support groups, an art experiential project and training workshops for patients, but all have had limited success due primarily to the lack of affordable transportation and/or parking at the GMP.
UCSF’s medical system has suffered tremendous financial setbacks in the volatile managed care market. This has affected the institution’s ability to provide resources and services, which has impacted the CCT project. For example, project staff was asked to reside in a rodent-infested office, and having little access to social workers, nurses and psychosocial services has left the team overwhelmed.
The project team, consisting of a physician, social worker, project coordinator, pharmacist, psychologist, clinical artist, chaplain and family services nurse, meets weekly, which helps build a sense of cohesiveness and shared mission. The project is unique in that it involves a case management model, led by a social worker. The addition of a pharmacist has significantly improved patient care and the role of the chaplain is integral. A survey found that 60 percent of providers and patients believe that addressing patients’ spiritual concerns was a very important part of the medical encounter.
One challenge faced by the team was difficulty in recruiting volunteers. The result was a creative approach wherein graduate medical students are given graduate level elective credit to attend a class on how to be a volunteer advocate, taught by CCT and offered by UCSF School of Medicine. The class participants then spend time as volunteer advocates. The course lasts 10 weeks and has had about 30 students – mostly from the school of pharmacy.
A comprehensive family caregiver-training course is available to family members of CCT patients, designed to provide practical information about caring for seriously ill family members. This course is spearheaded by Celi Adams, RN, a recipient of RWJF’s Community Health Leadership Award.
A patient support group was planned and an extensive manual developed. However, the formal, closed support group never was offered due to lack of a critical number of committed members. Chapters from the support group manual were used in a series of individual group meetings and classes, collectively called the "TGIF" sessions ("Thank God It's Friday").
Exportable Products/Tools
Communications
They have conducted a fair amount of dissemination activities including several abstracts of CCT findings in the Journal of General Internal Medicine. The team also conducted several presentations at the Society of General Internal Medicine. CCT was highlighted in the special JAMA series; and they participated in a local television program accompanying “On Our Own Terms.”
They have placed press releases in local papers and institutional news and many internal presentations.
They recently submitted a communications grant to create a Web site that records and illustrates the many dimensions of a care community for patients at the beginning of the end of life. The project will focus on two underlying premises of the CCT project:
They plan a combination of audio, video and narrative content.
Words of Wisdom from the Project
CCT project leaders write that success lies on the shoulders of a committed social worker-- attaching even a limited case-management model to a general medicine practice requires a very pro-active social worker who is comfortable gently insinuating her/himself in the traditionally private out-patient doctor-patient relationship. It also lies on a hard-working project coordinator.
The project also recommends personal, physician-to-physician relationships with PCPs. This model was dependent on referrals and participation from the PCPs. Identifying early adopters among the PCPs and working with them to generate referrals was critical.
Try to get more buy-in from powers-that-be before the project starts. If the project is doing work useful to the powers-that-be, they may be more receptive to incorporating innovations. Put more support into fewer people. A few dedicated individuals do most work.
Make sure advance directives are visible in the home. One patient was resuscitated by EMTs and admitted to the ICU at an outside hospital, despite her wish to die at home. Her advance directive was not visible in the home when the EMTs arrived and was consequently ignored. Project staff implemented a plan to have all advance directives attached to the refrigerator with a magnet.
Think big, plan small. Everything takes way longer and is more complex than you expect.
