A multi-step education model for advancing competencies in geriatrics and interprofessional collaboration for health students.

At a time when the older adult population is increasing exponentially and health care agencies are fraught with crisis-level short-handedness and burnout, addressing the Quadruple Aim of enhancing patient experience, improving population health, reducing costs, and improving the work life of health care providers is more crucial than ever. A multi-step education model was designed to advance competencies in geriatrics and Interprofessional Collaborative Practice (IPCP) for health profession students focused on each element of the Quadruple Aim. The goals of this education were to equip students with knowledge and experience to provide team-based care for older adults and achieve satisfaction with the education program. The education steps consisted of online didactics, team icebreaker, skills practice, professional huddles, and interprofessional simulation with debriefing. Over 2,300 students and 87 facilitators from 16 professions completed the training over three years. A positive statistically significant increase was found between pre- and post-measures of IPCP competency, knowledge, and attitudes. Additionally, high satisfaction with the education was reported by students and facilitators. By providing positive geriatric education and experiences for health students to work in interprofessional teams, it can translate into future improvements in older adult population health, health care provider job satisfaction, and reduced health care costs.

Impact of Referring Team Characteristics on Inpatient Palliative Care Consultation Rate at a Comprehensive Cancer Center.

Background: No prior study addresses the impact of admitting team characteristics on inpatient palliative care (PC) consultation rate in cancer patients. Understanding consultation rate differences among admitting service types may reveal PC access disparities for patients who would benefit from consultation. Aim: To determine the impact of admitting service characteristics (teaching vs. nonteaching and surgical vs. medical) on inpatient PC consultation rates. Methods: A six-month cross-sectional study was performed at an academic comprehensive cancer center. Inpatient PC consultations and follow-up visits were compared to total admissions by admitting service category. Results: Five thousand six hundred ninety-seven admissions resulted in 710 new PC consultations and 2494 follow-up visits. Patients admitted to medical services had highest odds of PC consultation, while data for teaching services were mixed. There was no difference in follow-up visits. Conclusions: Significant differences between medical and surgical service PC consultation rates may indicate specialty PC access disparities solely based on their admitting service.

Training to Promote Empathic Communication in Graduate Medical Education: A Shared Learning Intervention in Internal Medicine and General Surgery.

Background: Empathic communication skills have a growing presence in graduate medical education to empower trainees in serious illness communication. Objective: Evaluate the impact, feasibility, and acceptability of a shared communication training intervention for residents of different specialties. Design: A randomized controlled study of standard education v. our empathic communication skills-building intervention: VitalTalk-powered workshop and formative bedside feedback using a validated observable behavioral checklist. Setting/Subjects: During the 2018-2019 academic year, our intervention was implemented at a large single-academic medical center in the United States involving 149 internal medicine and general surgery residents. Measurements: Impact outcomes included observable communication skills measured in standardized patient encounters (SPEs), and self-reported communication confidence and burnout collected by surveys. Analyses included descriptive and inferential statistics, including independent and paired t tests and multiple regression model to predict post-SPE performance. Results: Of residents randomized to the intervention, 96% (n = 71/74) completed the VitalTalk-powered workshop and 42% (n = 30/71) of those residents completed the formative bedside feedback. The intervention demonstrated a 33% increase of observable behaviors (p < 0.001) with improvement in all eight skill categories, compared with the control who only showed improvement in five. Intervention residents demonstrated improved confidence in performing all elicited communication skills such as express empathy, elicit values, and manage uncertainty (p < 0.001). Conclusions: Our educational intervention increased residents' confidence and use of essential communication skills. Facilitating a VitalTalk-powered workshop for medical and surgical specialties was feasible and offered a shared learning experience for trainees to benefit from expert palliative care learning outside their field.

Looking Back, and Ahead: A Call to Action for Increasing the Hospice and Palliative Medicine Specialty Pipeline.

Thanks to the efforts of many individuals and organizations, the field of Hospice and Palliative Medicine (HPM) has undergone unprecedented growth over the last two decades. To meet the needs of seriously ill patients and families in inpatient, outpatient community setting in the future, the field of HPM must develop innovative strategies to expand the specialist workforce pipeline. With 148 programs participating in the National Residency Matching Program and 285 matched applicants in 2019, the specialty of HPM can barely replace those who are retiring or leaving the field. We call for a renewed and coordinated effort to increase the applicant pool for HPM fellowship positions, as well as greater access to specialist HPM training through expanded traditional fellowship programs and innovative specialist training pathways. Without such an expansion, our specialty will struggle to serve those patients and families who need us most.

Development of Subspecialty-Specific Reporting Milestones for Hospice and Palliative Medicine Fellowship Training in the U.S.

Continuing the transition to competency-based education, Hospice and Palliative Medicine (HPM) fellowship programs began using context-free reporting milestones (RMs) for internal medicine subspecialties in 2014 but quickly recognized that they did not reflect the nuanced practice of the field. This article describes the development of 20 subspecialty-specific RMs through consensus group process and vetting by HPM educators. A workgroup of content experts used an iterative consensus building process between December 2017 and February 2019 to draft new RMs and create a supplemental guide that outlines the intent of each RM, examples of each developmental trajectory, assessment methods, and resources to guide educators. Program directors, program coordinators, and designated institutional officers were contacted directly to solicit feedback. Most respondents agreed or strongly agreed that each RM represented a realistic progression of knowledge, skills, and behaviors, and that the set of milestones adequately discriminated between meaningful levels of competency. Similarly, respondents felt that the supplemental guide was a useful resource. The result is a set of carefully developed and broadly vetted RMs that represent a progression of development for HPM physicians during one year of clinical fellowship training.

Building Provider-Caregiver Partnerships: Curricula for Medical Students and Residents.

PROBLEM: A disconnect exists between caregivers and health care providers, resulting in fragmented communication, which increases caregiver stress and compromises patient care. Although providers have a responsibility to recognize caregiver burden, they receive scant training on issues important to caregivers. APPROACH: From 2014 to 2017, as part of the Building Caregiver Partnerships Through Interprofessional Education project-a collaborative effort between Northeast Ohio Medical University and Summa Health-the authors developed curricula to foster effective partnerships between health care providers and caregivers by exposing medical students and residents to highly personal caregiving narratives. The curricula center on a short film featuring 4 families representing diverse caregiving experiences. The authors crafted several discussion guides, case-based learning exercises, structured clinical encounters, team-based simulations, and clinical cases as companion educational tools for the film. OUTCOMES: Medical students reported the educational tools piloted to be valuable in broadening their understanding of caregivers' needs, while residents reported the educational tools piloted to also be valuable in improving their communication and building partnerships with caregivers. Undergraduate and graduate faculty reported finding the pilots valuable. NEXT STEPS: Future goals include conducting an outcome evaluation, based on ACGME milestones, to identify and examine clinical outcomes to determine whether communication increases and quality of care improves as a result of the project. The authors would also like to include caregivers in the evaluation. Finally, because caregiving is best addressed from a team approach, the authors plan to pilot the project at other health professions programs.

Development of Curricular Milestones for Hospice and Palliative Medicine Fellowship Training in the U.S.

CONTEXT: A physician workgroup of the American Academy of Hospice and Palliative Medicine sought to define curricular milestones (CMs) for hospice and palliative medicine (HPM) Fellowship Programs. The developed list of CMs would serve as components upon which to organize curriculum and standardize what to teach during training. These would complement entrustable professional activities previously developed by this group and new specialty-specific reporting milestones (RMs) for HPM developed through the Accreditation Council for Graduate Medical Education. OBJECTIVES: The objective of this study was to develop and vet CMs for HPM fellowships in the U.S. METHODS: A draft of CMs was developed through an iterative consensus group process with repeated cycles of drafting, analyzing, and revising by a broadly representative expert workgroup who then gained input from HPM educators at a national meeting workshop. The CM draft was subsequently revised and then vetted through a national survey to 203 fellowship educators. Respondents were asked to "keep," "revise," or "exclude" each proposed CM with space for comments. An agreement of 75% among respondents was set as the criteria a priori for keeping a CM. Eighty-four of the 203 potential respondents participated in the survey. All items met the minimum agreement level of 75% or greater recommending keeping the CM. Greater than 85% of the respondents agreed to keep 19 of the 22 CMs with no revisions. Comments for revisions on other CMs were primarily related to changes in language and formatting, not conceptual underpinnings. CONCLUSION: A group consensus method strengthened by inclusion of a national survey to HPM fellowship educators resulted in a CM document that is both carefully developed and broadly vetted. Along with entrustable professional activities and new specialty-specific RMs, these CMs offer educators and trainees tools to create more comprehensive curricula and behaviorally based assessment tools for HPM fellowships and their stakeholders.

Use of Film to Sensitize Medical Students to Issues of Family Caregiving.

BACKGROUND AND OBJECTIVE: Families are the backbone of our long-term care system, managing complicated illnesses, providing direct care, and assisting with the day-to-day functioning of elderly patients. Medical education, however, provides students with little, if any, exposure to the challenges faced by family caregivers or how best to communicate with them to optimize patient care. We assessed the value of an educational program combining film and discussion as a means of sensitizing third-year medical students to caregiver issues. During their family medicine clerkship, third-year medical students at Northeast Ohio Medical University view the film, No Roadmap: Caregiver Journeys and discuss issues of family caregiving. METHODS: A mixed-methods approach was used to evaluate the program, including a qualitative focus group with clerkship preceptors and ongoing quantitative student evaluations. RESULTS: Preceptors reported that students related to the film in highly personal ways, often recounting experiences within their own families, and gained a greater appreciation of caregivers. Three years of student evaluations (n=403) were used to validate preceptor comments. Students agreed that the program helped them establish a comfortable relationship with caregivers, increased their awareness of caregiver challenges and rewards, and provided valuable insights into caregiver experiences. CONCLUSIONS: Film depicting compelling narratives of caregiver journeys, coupled with guided discussion, is a valuable strategy for increasing student awareness of the important role of caregivers.

Revisiting 'awareness contexts' in the 21st century hospital: How fragmented and specialized care shape patients' Awareness of Dying.

In 1965, Glaser and Strauss (1965) offered the concept of "awareness contexts" to explain what patients in hospitals do or don't know about their death trajectories. Awareness ranges from closed (where patients are completely unaware and family and providers protect "the secret") to open (where all parties communicate openly and honestly). While closed awareness was the norm in 1960s, open awareness is now considered standard practice in US, a reflection of mounting evidence that patients, families, and providers benefit from clear and honest communication at end of life (Seale et al., 1997; Wright et al., 2008). Despite the known benefits of open awareness, many terminal patients remain unaware or confused about their prognoses (Chen et al., 2017). This paper asks why, in an era of open awareness, are patients and families uncertain about dying? To answer this question, we focus on an aspect of Glaser and Strauss's theory that remains relatively understudied by researchers, namely the role of institutional and organizational realities in shaping awareness contexts. Based on interviews with 43 family members of deceased patients who died at General Hospital in the Midwestern US, we argue that two related conditions in hospitals-the increased specialization of medical professionals and the fragmentation of patient care-serve as important context for the death awareness of patients and families.

Development of Entrustable Professional Activities for Hospice and Palliative Medicine Fellowship Training in the United States.

CONTEXT: Entrustable Professional Activities (EPAs) represent the key physician tasks of a specialty. Once a trainee demonstrates competence in an activity, they can then be "entrusted" to practice without supervision. A physician workgroup of the American Academy of Hospice and Palliative Medicine sought to define Hospice and Palliative Medicine (HPM) EPAs. OBJECTIVE: The objective of this study was to describe the development of a set of consensus EPAs for HPM fellowship training in the United States. METHODS: A set of HPM EPAs was developed through an iterative consensus process involving an expert workgroup, vetting at a national meeting with HPM educators, and an electronic survey from a national registry of 3550 HPM physicians. Vetting feedback was reviewed, and survey data were statistically analyzed. Final EPA revisions followed from the multisource feedback. RESULTS: Through the iterative consensus process, a set of 17 HPM EPAs was created, detailed, and revised. In the national survey, 362 HPM specialists responded (10%), including 58 of 126 fellowship program directors (46%). Respondents indicated that the set of 17 EPAs well represented the core activities of HPM physician practice (mean 4.72 on a five-point Likert scale) and considered all EPAs to either be "essential" or "important" with none of the EPAs ranking "neither essential, nor important." CONCLUSIONS: A set of 17 EPAs was developed using national input of practicing physicians and program directors and an iterative expert workgroup consensus process. The workgroup anticipates that EPAs can assist fellowship directors with strengthening competency-based training curricula.

Results of the promoting effective advance care planning for elders (PEACE) randomized pilot study.

The specific aim of the PEACE pilot study was to determine the feasibility of a fully powered study to test the effectiveness of an in-home geriatrics/palliative care interdisciplinary care management intervention for improving measures of utilization, quality of care, and quality of life in enrollees of Ohio's community-based long-term care Medicaid waiver program, PASSPORT. This was a randomized pilot study (n=40 intervention [IG], n=40 usual care) involving new enrollees into PASSPORT who were >60 years old. This was an in-home interdisciplinary chronic illness care management intervention by PASSPORT care managers collaborating with a hospital-based geriatrics/palliative care specialist team and the consumer's primary care physician. This pilot was not powered to test hypotheses; instead, it was hypothesis generating. Primary outcomes measured symptom control, mood, decision making, spirituality, and quality of life. Little difference was seen in primary outcomes; however, utilization favored the IG. At 12 months, the IG had fewer hospital visits (50% vs. 55%, P=0.65) and fewer nursing facility admissions (22.5% vs. 32.5%, P=0.32). Using hospital-based specialists interfacing with a community agency to provide a team-based approach to care of consumers with chronic illnesses was found to be feasible. Lack of change in symptom control or quality of life outcome measures may be related to the tools used, as these were validated in populations closer to the end of life. Data from this pilot study will be used to calculate the sample size needed for a fully powered trial.

Assessing the financial impact of an inpatient acute palliative care unit in a tertiary care teaching hospital.

BACKGROUND: Evidence suggests palliative care consult services yield cost improvements; few studies have examined the impact of an inpatient palliative care unit on hospital costs. OBJECTIVE: This study estimates the cost avoidance of a single hospital's acute palliative care unit (APCU), building upon previous studies (1) by limiting pre-APCU costs to two days pre-APCU transfer, thereby minimizing bias from higher-cost first days of admission, and (2) by not limiting the study to cancer patients or patients who died, thereby presenting more comprehensive APCU costs. DESIGN: This retrospective study compares direct costs of care on an APCU with costs pre-APCU transfer from general medical units, intensive care units (ICU), and the emergency department (ED), and compares the direct costs of APCU patients with those of control patients. The data were entered into an SPSS(®) 17.0 (SPSS Inc., Chicago, IL) statistical software database. Paired and independent samples t-tests were conducted to test cost differences. SETTING/SUBJECTS: Study patients were admitted or transferred to the APCU from October 2008 through January 2009. Control patients were inpatients during the same time period and met several matching criteria. MEASUREMENTS: The hospital's finance department provided direct costs, case mix index (CMI), and geometric mean length of stay, and the Department of Quality and Resource Management provided patients' demographic and administrative data. RESULTS: Of 209 patients transferred to the APCU, 50% transferred from a medical unit, 32% from an ICU, and 18% from the ED. Annualized, the total cost avoidance realized by transfers to the APCU was $848,556, over half of which came from ICU to APCU transfers. CONCLUSIONS: Cost avoidance is realized when patients transfer to an APCU even when conservative pre-APCU cost measures are used and when patients with varying diagnoses and discharge outcomes are included. This study demonstrates a replicable methodology for estimating the financial impact of an APCU.

Physician knowledge, attitude, and experience with advance care planning, palliative care, and hospice: results of a primary care survey.

PURPOSE: To evaluate primary care physicians' understanding of and experience with advance care planning (ACP), palliative care, and hospice and how this might affect their utilization of these services. METHODS: Investigator-generated survey. RESULTS: Older age, more years in practice, and more personal and professional experience with ACP were correlated with an increase in the percentage of patients with progressive, chronic life-limiting diseases with whom physicians discussed advance directives. Overall, 97.5% of physician's expressed comfort in discussing ACP yet reported discussing advance directives with only 43% of appropriate patients. DISCUSSION: Often, discussions about ACP or referrals to palliative care or hospice do not occur until the patient is near the end of life. Our results indicate that primary care physician's personal and professional experience with ACP may be contributing to some of the barriers to these discussions.

Palliative and end-of-life care for patients with ovarian cancer.

Palliative care improves the quality of life of patients and their families through the prevention and treatment of distressing symptoms while addressing the psychological, social, and spiritual aspects of patient care. Emerging paradigms of delivery promote early involvement in the disease trajectory and specialty approaches to care. Interdisciplinary assessment and shared decision making are important components. Throughout the disease course, aggressive symptom management can improve patients' quality of life and their ability to tolerate and continue treatment. End-of-life care focuses on comfort, control, meaning, and support that become particularly intense when death is imminent.

Functions and outcomes of a clinical medical ethics committee: a review of 100 consults.

CONTEXT: Established in 1997, Summa Health System's Medical Ethics Committee (EC) serves as an educational, supportive, and consultative resource to patients/families and providers, and serves to analyze, clarify, and ameliorate dilemmas in clinical care. In 2009 the EC conducted its 100th consult. In 2002 a Palliative Care Consult Service (PCCS) was established to provide supportive services for patients/families facing advanced illness; enhance clinical decision-making during crisis; and improve pain/symptom management. How these services affect one another has thus far been unclear. OBJECTIVES: This study describes EC consults: types, reasons, recommendations and utilization, and investigates the impact the PCCS may have on EC consult requests or recommendations. METHODS: Retrospective reviews of 100 EC records explored trends and changes in types of consults, reasons for consults, and EC recommendations and utilization. RESULTS: There were 50 EC consults each in the 6 years pre- and post-PCCS. Differences found include: (1) a decrease in number of reasons for consult requests (133-62); (2) changes in top two reasons for EC consult requests from 'Family opposed to withdrawing life-sustaining treatment (LST)' and 'Patient capacity in question' to 'Futility' and 'Physician opposed to providing LST'; (3) changes in top two recommendations given by the EC from 'Emotional Support for Patient/Family' and 'Initiate DNR Order' to 'Comfort Care' and 'Withdraw Treatment.' Overall, 88% of recommendations were followed. CONCLUSION: PCCS availability and growth throughout the hospital may have influenced EC consult requests. EC consults regarding family opposition to withdrawing LST and EC recommendations for patient/family support declined.

The Promoting Effective Advance Care for Elders (PEACE) randomized pilot study: theoretical framework and study design.

Practice guidelines are available for hospice and palliative medicine specialists and geriatricians. However, these guidelines do not adequately address the needs of patients who straddle the 2 specialties: homebound chronically ill patients. The purpose of this article is to describe the theoretical basis for the Promoting Effective Advance Care for Elders (PEACE) randomized pilot study. PEACE is an ongoing 2-group randomized pilot study (n=80) to test an in-home interdisciplinary care management intervention that combines palliative care approaches to symptom management, psychosocial and emotional support, and advance care planning with geriatric medicine approaches to optimizing function and addressing polypharmacy. The population comprises new enrollees into PASSPORT, Ohio's community-based, long-term care Medicaid waiver program. All PASSPORT enrollees have geriatric/palliative care crossover needs because they are nursing home eligible. The intervention is based on Wagner's Chronic Care Model and includes comprehensive interdisciplinary care management for these low-income frail elders with chronic illnesses, uses evidence-based protocols, emphasizes patient activation, and integrates with community-based long-term care and other community agencies. Our model, with its standardized, evidence-based medical and psychosocial intervention protocols, will transport easily to other sites that are interested in optimizing outcomes for community-based, chronically ill older adults.