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The team wanted to establish a standard way of getting people into palliative care and coordinating their care. All of these changes were tested first on a small number of patients. As the team saw positive results, they increased the number of staff participating in the project and thus increased the patients receiving palliative services. We have organized a small series of changes into each of the "tests" outlined below.
Test 1: Establish a palliative care referral process.
The team designed and tested a process that included who should be referred, procedures for making the referral, and standard palliative care orders.
Test 2: Assign a case manager to coordinate palliative services.
The case manager is responsible for finding and receiving consults, coordinating services for patients, maintaining weekly contact with the patients not admitted to hospice, and serving as a liaison between outpatient clinics and hospice providers. This person is the "glue" that holds the care together, who speeds and smooths all transitions. As a result, social work referrals increased 50 percent and pastoral care referrals increased 15-fold (from 6 to 94 percent of patients).
Test 3: Train nursing staff in pain assessment.
Once staff members learned about uniform pain assessment and were consistently able to assess patients' pain levels, it became easier to manage pain using palliative care consults and standard orders for pain. Eventually, outpatient clinic nurses also tried out routinely making follow-up phone calls to patients at home to assess pain levels and response to medication changes. They found that most patients continued to have serious pain and that virtually all of them could get this pain under control with one or two phone calls.
Test 4: Use multidisciplinary team conferences weekly to plan and modify care.
Multidisciplinary team meetings allow all members of the care team to see the spectrum of needs and respond in a coordinated manner.
Test 5: Establish a referral model (algorithm) to increase access and continuity between primary care and oncology.
Specific rules and procedures about who should be referred and when were used to help primary care and oncology physicians improve access to appropriate care.
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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved. For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ]. |
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