3. Develop Changes
The team wanted to establish more accessible palliative care, with the goal of enabling hospital staff to provide appropriate pain and symptom management and to get needed referral services. After learning about other palliative care services, Parkland decided to create a clinical position for a case manager to coordinate all palliative care. In this way, the referral process would be standardized, a bottleneck that slowed referrals would be removed, and access to needed information would be greatly enhanced.
4. Test ChangesThe 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 and who speeds and smoothes all transitions. As a result, social work referrals increased 50% and pastoral care referrals increased 15-fold (from 6 to 94% 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 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 see how best to get key needs met.
This text is derived from the book Improving Care for the End of Life : A Sourcebook for Health Care Managers and Clinicians.