The value equation for specialist palliative care: design and delivery principles.

The value of specialist palliative care (SPC) is multi-faceted. Patients, families, healthcare providers, health systems and payors all benefit in different ways when SPC is included in the care of those with serious illness; they all have a shared interest in the availability and success of SPC. We propose a new value equation for SPC: SPC services must employ optimal design and standardized delivery of SPC to ensure that the payment model, care model, and needs of the patients are all aligned; and suitable payment models are necessary to provide stable, sustainable resources for the interdisciplinary palliative care teams; when these conditions are met, the cascade of beneficial outcomes of SPC can be produced reliably. We propose a set of 10 design and delivery principles describing these inputs and outcomes, applicable to SPC in all settings-hospital, clinic, and home. Amidst shifts in health policy and financing, the SPC field in the US continues to evolve with new innovations, additional evidence, and a clearer vision of what is valuable. An enduring component of the value equation of SPC continues to be the moderation of the total cost of care for payors. This articulation of the value equation for SPC is based on evidence and experience of palliative care providers and payors in the US, but the framework and principles are likely useful to guide and evaluate SPC in other countries as well.

2011 John M. Eisenberg Patient Safety and Quality Awards. Mentored implementation: building leaders and achieving results through a collaborative improvement model. Innovation in patient safety and quality at the national level.

BACKGROUND: The Society of Hospital Medicine (SHM) created "Mentored Implementation" (MI) programs with the dual aims of educating and mentoring hospitalists and their quality improvement (QI) teams and accelerating improvement in the inpatient setting in three signature programs: Venous Thromboembolism (VTE) Prevention, Glycemic Control, and Project BOOST (Better Outcomes for Older adults through Safe Transitions). METHODS: More than 300 hospital improvement teams were enrolled in SHM MI programs in a series of cohorts. Hospitalist mentors worked with individual hospitals/health systems to guide local teams through the life cycle of a QI project. Implementation Guides and comprehensive Web-based "Resource Rooms," as well as the mentor's own experience, provided best-practice definitions, practical implementation tips, measurement strategies, and other tools. E-mail interactions and mentoring were augmented by regularly scheduled teleconferences; group webinars; and, in some instances, a site visit. Performance was tracked in a centralized data tracking center. RESULTS: Preliminary data on all three MI programs show significant improvement in patient outcomes, as well as enhancements of communication and leadership skills of the hospitalists and their QI teams. CONCLUSIONS: Although objective data on outcomes and process measures for the MI program's efficacy remain preliminary at this time, the maturing data tracking system, multiple awards, and early results indicate that the MI programs are successful in providing QI training and accelerating improvement efforts.

Doing More with the Same: Comparing Public and Private Hospital Palliative Care within California.

Background: Public and private hospitals treat different patient populations, which may impact resources to deliver palliative care (PC). Objectives: Compare public and private hospital PC service structures, processes, and treatment outcomes. Design: Retrospective data analysis of the Palliative Care Quality Network between 2018 and 2019. Settings/Subjects: Six public and 40 private California hospitals provided PC consultations to 4244 and 38,354 adults, respectively. Measurements: PC team and patient characteristics, care processes, and treatment outcomes. Results: Public and private hospital PC services had similar full-time equivalent/100 beds (1.2 vs. 1.4, p = 0.4). Public hospital patients were younger (65.2 vs. 73.5, p < 0.001), less likely to be non-Hispanic Caucasian (22.5% vs. 57.5%, p < 0.001), or English speaking (51.1% vs. 79.9%, p < 0.001). Public hospital patients had more moderate/severe pain (21.3% vs. 19.3, p < 0.03), anxiety (12.4% vs. 9.2%, p < 0.001), nausea (6.5% vs. 4.7%, p < 0.001), and dyspnea (11.0% vs. 8.6%, p < 0.001). Both hospitals equally improved pain (70.9% vs. 70.5%, p = 0.83) and nausea (82.0% vs. 87.6%, p = 0.09), but public hospitals were less effective at improving anxiety (67.3% vs. 78.4%, p = 0.002) and dyspnea (58.4% vs. 67.9%, p = 0.05). Although there was no difference in hospital length of stay (public = 10.2 days vs. private = 9.5 days, p = 0.07), public hospitals conducted more patient visits (2.6 vs. 1.8, p < 0.001). They also more often clarified code status (87.7% vs. 84.4%, p < 0.001) and surrogate decision maker (94.9% vs. 89.9%, p < 0.001). Conclusions: Public hospital PC teams treat a more diverse symptomatic population. Yet, they achieved comparable outcomes with similar staffing to private hospitals. These findings have important ramifications for policy makers and public institution leaders.

Student performance problems in medical school clinical skills assessments.

BACKGROUND: Though most medical schools administer comprehensive clinical skills assessments to identify students who have not achieved competence, the types of problems uncovered by these exams have not been characterized. METHOD: The authors interviewed 33 individuals responsible for remediation after their schools' comprehensive assessments, to explore their experience with the problems students demonstrate and strategies for and success with remediation. RESULTS: Respondents perceived that technique problems in history taking and physical examination were readily correctable, but that poor performance resulting from inadequate knowledge or poor clinical reasoning ability was more difficult to ameliorate. Interpersonal skill deficiencies, which often manifested as detachment from the patient, and professionalism problems attributed to lack of insight, were most refractory to remediation. CONCLUSIONS: Poor performance in comprehensive assessments often indicates underlying deficiencies in cognitive ability, communication skills, or professionalism. The challenge of remediating these deficiencies late in medical school calls for earlier identification and intervention.

Impact of the United States Medical Licensing Examination Step 2 Clinical Skills exam on medical school clinical skills assessment.

BACKGROUND: Medical schools face a new responsibility to prepare students for the United States Medical Licensing Exam Step 2 Clinical Skills (CS) exam. METHOD: We conducted semistructured interviews with 25 leaders of medical school clinical skills assessments to explore purposes of in-house assessment and the impact of the Step 2 CS exam. Interviews were coded to identify major themes. RESULTS: Competency assessment, student and curricular feedback, and preparation for the licensing exam emerged as major purposes of in-house exams. Participants asserted that in-house exams assessed faculty-identified competencies, although not all schools had defined competencies. Limited resources made balancing formative and summative assessment goals problematic for some schools. Curricular feedback was general but valued. All schools, even those that disagreed with aspects of the licensing exam, acknowledged their roles in preparing students for the Step 2 CS. CONCLUSION: An external licensing requirement engenders debate and motivates changes in clinical skills assessment and, in some cases, curricula.

Effect of a Home-Based Palliative Care Program on Healthcare Use and Costs.

OBJECTIVES: To evaluate the nonclinical outcomes of a proactive palliative care program funded and operated by a health system for Medicare Advantage plan beneficiaries. DESIGN: Observational, retrospective study using propensity-based matching. SETTING: A health system in southern California. PARTICIPANTS: Individuals who received the intervention between 2007 and 2014 (n = 368) were matched with 1,075 comparison individuals within each of four disease groups: cancer, chronic obstructive pulmonary disease, heart failure, and dementia. All were known to be dead at the time of the retrospective study, were Medicare Advantage beneficiaries, and had 2 years of usage data before death. Median age at death for each disease group was older than 80. INTERVENTION: Home- and clinic-based palliative care (PC) services provided by a multidisciplinary team. MEASUREMENTS: Outcomes included hospital costs, other healthcare costs, readmission rates, hospital admissions and bed days, intensive care unit use in final 30 days of life, and death within 30 days of an admission. RESULTS: Intervention participants in all four disease groups had less hospital use and lower hospital costs nonintervention participants, which drove lower overall healthcare costs. In the final 6 months of life, healthcare costs for the intervention groups stayed largely the same from month to month, whereas costs for comparison participants increased dramatically. CONCLUSION: In the context of an alternative payment model in which the provider was "at risk" of bearing the costs of care, a proactive PC program helped to avoid the escalation in hospital use and costs commonly seen in the final months of life.

A national study of medical student clinical skills assessment.

BACKGROUND: This study describes comprehensive standardized patient examinations in medical schools nationally. METHOD: We surveyed 121 medical school curriculum deans regarding their use of standardized patient assessments. Questions addressed examination characteristics, funding sources, and collaborations. RESULTS: A total of 91 of 121 curriculum deans responded (75% response rate). The majority (84%) of respondents report conducting a comprehensive clinical skills assessment during the third or fourth year of medical school. Most programs are funded with dean's office monies. Although many collaborate with other institutions for examination development, the majority of schools score and remediate students independently. Two-thirds of all respondents (61/91) report that the new standardized patient licensing requirement elevates the importance of in-house clinical skills examinations. CONCLUSIONS: Most medical schools now conduct comprehensive clinical skills assessments after the core clerkships, and collaboration is common. These results suggest increasing emphasis on clinical and communication skills competency and opportunities for collaborative research.

The Business Case for Palliative Care: Translating Research Into Program Development in the U.S.

Specialist palliative care (PC) often embraces a "less is more" philosophy that runs counter to the revenue-centric nature of most health care financing in the U.S. A special business case is needed in which the financial benefits for organizations such as hospitals and payers are aligned with the demonstrable clinical benefits for patients. Based on published studies and our work with PC programs over the past 15 years, we identified 10 principles that together form a business model for specialist PC. These principles are relatively well established for inpatient PC but are only now emerging for community-based PC. Three developments that are key for the latter are the increasing penalties from payers for overutilization of hospital stays, the variety of alternative payment models such as accountable care organizations, which foster a population health management perspective, and payer-provider partnerships that allow for greater access to and funding of community-based PC.

The impact of follow-up telephone calls to patients after hospitalization.

We studied whether pharmacists involved in discharge planning can improve patient satisfaction and outcomes by providing telephone follow-up after hospital discharge. We conducted a randomized trial at the General Medical Service of an academic teaching hospital. We enrolled General Medical Service patients who received pharmacy-facilitated discharge from the hospital to home. The intervention consisted of a follow-up phone call by a pharmacist 2 days after discharge. During the phone call, pharmacists asked patients about their medications, including whether they obtained and understood how to take them. Two weeks after discharge, we mailed all patients a questionnaire to assess satisfaction with hospitalization and reviewed hospital records. Of the 1,958 patients discharged from the General Medical Service from August 1, 1998 to March 31, 1999, 221 patients consented to participate. We randomized 110 to the intervention group (phone call) and 111 to the control group (no phone call). Patients returned 145 (66%) surveys. More patients in the phone call than the no phone call group were satisfied with discharge medication instructions (86% vs. 61%, P = 0.007). The phone call allowed pharmacists to identify and resolve medication-related problems for 15 patients (19%). Twelve patients (15%) contacted by telephone reported new medical problems requiring referral to their inpatient team. Fewer patients from the phone call group returned to the emergency department within 30 days (10% phone call vs. 24% no phone call, P = 0.005). A follow-up phone call by a pharmacist involved in the hospital care of patients was associated with increased patient satisfaction, resolution of medication-related problems, and fewer return visits to the emergency department.

Fate of polydimethylsilicone in biosolids-amended field plots.

This research examined the fate of polydimethylsilicones (PDMS) in agricultural test plots amended with municipal biosolids. This 4 yr field study involved addition of 0, 15, and 100 Mg ha(-1) of municipal biosolids, which contained ambient concentrations of PDMS (1272 mg kg(-1) biosolids), to corn and soybean test plots. Soil samples collected at intermittent time intervals were analyzed for soil water, soil organic C, extractable PDMS and PDMS hydrolysis products. Above normal precipitation during the field study maintained soil water levels in excess of 100 g kg(-1) for most of the testing period of 1994-1998. Under these conditions half-lives for PDMS (based on field dissipation data) ranged from 876 to 1443 d. When biosolids amended soil samples were brought into the laboratory and subjected to more rapid drying, >80% of the PDMS was transformed to lower molecular weight hydrolysis products within 20 d. No difference in relative PDMS transformation rates were evident for soils that received PDMS in the form of a biosolids amendment or directly dosed to the soil (in the absence of biosolids) indicating little if any effect of direct PDMS-biosolids interactions on PDMS transformation rates. These results support that the overriding factor controlling the fate of PDMS in field soils is the soil moisture content.

Leveraging external resources to grow and sustain your palliative care program: a call to action.

Hospital-based palliative care is becoming increasingly prevalent. There is growing evidence that it is having a positive impact on patients and their loved ones. In 2008, national data indicated that 58.5% of hospitals with 50 or more beds had a palliative care program. Data from a 2008 survey of California acute care hospitals showed that although 33% of sites had inpatient consultation services, one in five had been operational for only one year. As nascent palliative care programs grow, new issues arise and needs and plans change. Just as palliative care programs benefit from marketing and education plans, they also benefit from a plan to leverage external resources. Largely a missed opportunity, external resources such as organizations, networks, and experts can help palliative care service (PCS) leaders and team members gain information on everything from best practices to funding opportunities, while serving as sources for personal and professional support. The growing number of active PCSs and the increasing availability of support and expertise ensure that new programs no longer have to face challenges alone. Further, the steady increase in the number of new programs has created opportunities for those who are more experienced to serve as mentors for peers who are navigating the challenges of growing and sustaining a clinical service. The authors encourage both mentors and mentees to seek support from or provide support to others in the field. Leveraging the collective expertise and experiences in our field can ensure that palliative care continues to thrive and grow.

Palliative care services in California hospitals: program prevalence and hospital characteristics.

CONTEXT: In 2000, 17% of California hospitals offered palliative care (PC) services. Since then, hospital-based PC programs have become increasingly common, and preferred practices for these services have been proposed by expert consensus. OBJECTIVES: We sought to examine the prevalence of PC programs in California, their structure, and the hospital characteristics associated with having a program. METHODS: A total of 351 acute care hospitals in California completed a survey that determined the presence of and described the structure of PC services. Logistic regression identified hospital characteristics associated with having a PC program. RESULTS: A total of 324 hospitals (92%) responded, of which 44% (n=141) reported having a PC program. Hospitals most likely to have PC programs were large nonprofit facilities that belonged to a health system, had teaching programs, and had participated in a training program designed to promote development of PC services. Investor-owned sites (odds ratio [OR]=0.08; 95% confidence interval [CI]=0.03, 0.2) and city/county facilities (OR=0.06; 95% CI=0.01, 0.3) were less likely to have a PC program. The most common type of PC service was an inpatient consultation service (88%), staffed by a physician (87%), social worker (81%), chaplain (76%), and registered nurse (74%). Most programs (71%, n=86) received funding from the hospital and were expected to meet goals set by the hospital or health system. CONCLUSION: Although the number of hospital-based PC services in California has doubled since 2000, more than half of the acute care hospitals still do not provide PC services. Developing initiatives that target small, public, and investor-owned hospitals may lead to wider availability of PC services.

Characteristics of palliative care consultation services in California hospitals.

BACKGROUND: Although hospital palliative care consultation services (PCCS) can improve a variety of clinical and nonclinical outcomes, little is known about how these services are structured. METHODS: We surveyed all 351 acute care hospitals in California to examine the structure and characteristics of those hospitals with PCCS. RESULTS: We achieved a 92% response rate. Thirty-one percent (n=107) of hospitals reported having a PCCS. Teams commonly included physicians (87%), social workers (80%), spiritual care professionals (77%), and registered nurses (71%). Nearly all PCCS were available on-site during weekday business hours; 50% were available on-site or by phone in the weekday evenings and 54% were available during weekend daytime hours. The PCCS saw an average of 347 patients annually (median=310, standard deviation [SD]=217), or 258 patients per clinical full-time equivalent (FTE; median=250, SD=150.3). Overall, 60% of consultation services reported they are struggling to cope with the workload. On average, patients were in the hospital 5.9 days (median=5.5, SD=3.3) prior to referral to PCCS, and remained in the hospital for 6 days (median=4, SD=7.9) following the initial consultation. Patient and family meetings were an aspect of the consultation in 74% of cases. Overall, 21% of consultation patients were discharged home with hospice services and 25% died in the hospital. CONCLUSIONS: There is variation in how PCCS in California hospitals are structured and in the ways they engage with patients. Ultimately, linking PCCS characteristics and practices to patient and family outcomes will identify best practices that PCCS can use to maximize quality.

Consequences within medical schools for students with poor performance on a medical school standardized patient comprehensive assessment.

PURPOSE: Medical schools increasingly employ comprehensive standardized patient assessments to ensure medical students' clinical competence. The consequences of poor performance on the assessment and the institutional factors associated with imposing consequences are unknown. METHOD: In 2006, the investigators surveyed 122 U.S. medical school curriculum deans about comprehensive assessments using standardized patients after core clerkships, with questions about exam characteristics, institutional commitment to the examination (years of experience, exam infrastructure, clerkship director involvement), academic consequences of failing the assessment, and satisfaction with remediation. RESULTS: Ninety-three of 122 (76%) deans responded. Eighty-two (88%) conducted a comprehensive assessment in years three or four of medical school. Of those, required remediation was the only consequence of failing employed by 61 schools (74%), and only 39 (47%) required retesting for graduation. Participants were somewhat satisfied with (mean 3.45 out of maximum 5, SD 1.08) and confident in (3.37, SD 1.17) their remediation process. Satisfaction and confidence were associated with requiring remediation (P = .003) and retesting (P < .001), but experience with the exam, exam infrastructure, and clerkship director involvement were not. No school demographic characteristics or measures of institutional commitment were related to external reporting of students' comprehensive assessment scores. CONCLUSIONS: Despite the prevalence of comprehensive assessments, schools attach few academic consequences to poor performance. Educators are only moderately satisfied with their efforts to remediate poor performers. However, schools with greater trust in their remediation process than other schools are more likely to enforce consequences of poor performance.

Approaches to medical student remediation after a comprehensive clinical skills examination.

OBJECTIVE: Most US medical schools conduct comprehensive clinical skills assessments during Years 3 and 4. This study explores strategies used to identify and remediate students who perform poorly on these assessments. METHODS: In the academic year 2005-06, we conducted 33 semi-structured interviews with individuals responsible for standard setting in and remediation after their schools' comprehensive clinical skills assessments. We coded interviews to identify major themes. RESULTS: Prior to remediation, some schools employed a 'verification' step to ensure the accuracy of the failing score or need for remediation. Participants described a remediation process that included some or all of 3 steps. Firstly, students' specific learning deficits were diagnosed. Next, students participated in remedial activities such as performance review sessions or practice with standardised or actual patients. Lastly, students were re-tested, usually with a shorter, more formative examination. All participants reported using a diagnostic step, most offered or required remedial activities and many re-tested, although schools varied in the emphasis placed on each step. Many participants cited the individualised attention students received from remediation faculty staff as a strength of their approach, although they raised concerns about the substantial time demands placed on remediation faculty. Most respondents reported some dissatisfaction with their school's remediation process, particularly uncertainty about efficacy or rigour. CONCLUSIONS: Schools vary in the intensity and scope of remediation offered to students who perform poorly on clinical skills assessments. Although many schools invest significant resources in remediation, the effect of these efforts on students' subsequent clinical performance is unknown.