I have now had enough failures to be semi-successful.

1. I have now had enough failures to be semi-successful. Darrell Owens

2. The Power of One: Palliative Care when Team is Not an Option Darrell Owens, DNP Section Head | Attending Nurse Practitioner | Palliative Care CNS Supportive and Palliative Care, UWMC, NW Campus

3. Palliative Care Gold Standard Clinical Practice Guidelines for Quality Palliative Care 4th edition

4. Palliative Care is: • Appropriate at any stage in a serious illness, and it is beneficial when provided along with treatments of curative or life-prolonging intent. • Provided over time to patients based on their needs and not their prognosis. • Offered in all care settings and by various organizations, such as physician practices, health systems, cancer centers, dialysis units, home health agencies, hospices, and long-term care providers. • Focused on what is most important to the patient, family, and caregiver(s), assessing their goals and preferences and determining how best to achieve them. • Interdisciplinary to attend to the holistic care needs of the patient and their identified family and caregivers.

5. Guideline 1.1 IDT Since palliative care is holistic in nature, it is provided by a team of physicians, advanced practice registered nurses, physician assistants, nurses, social workers, chaplains, and others based on need. The palliative care team works with other clinicians and community service providers supporting continuity of care throughout the illness trajectory and across all settings, especially during transitions of care. Depending on care setting and patient population, IDT members may be certified palliative care specialists in their discipline and/or have additional training in palliative care. Primary care and other clinicians work with interdisciplinary colleagues to integrate palliative care into routine practice.

6. Palliative Care in Washington • According to GetPalliativeCare.org, there are 43 institutions that list inpatient palliative care as a service provided. • Twenty-three also provide data to the National Palliative Care Registry • No consistent definition of service name (Palliative Care, Supportive Care, Supportive and Palliative Care, Palliative and Supportive Care) • No standardization of services provided (spiritual care, social support, bereavement, grief, loss, 24-hour coverage, inpatient, outpatient, both) • No standardization of team members • Majority of teams have some type of prescriber (NP, MD, DO, PA)

7. Palliative Care in Washington • At least 60% of programs in Washington do not meet all aspects of NCP Guidelines. • Are these programs providing palliative care? • Who are the “customers?” • Do they believe we are providing palliative care? • Do patient and families believe they are getting palliative care? • Are they satisfied with the palliative care services they receive? • How do we know?

8. Palliative Care at Your Place • How is palliative care provided at your institution? • Who provides palliative care at your institution? • How is satisfaction measured? • What quality metrics are utilized?

9. Some History

10. Some More History

11. Crash and Burn

12. Downsizing • Close home-based practice (400 patients) • Reduce clinic to consulting only, two ½ days per week • Surrender TJC Accreditation • Cut inpatient program to Monday – Friday, business hours only • Reduce staffing to: • 2 NPs • 1 office LPN • Layoff 10 employees (Program Manager, RNs, LPNs, NPs)

13. One of two remaining NPs abandons ship! This Photo by Unknown Author is licensed under CC BY-SA-NC

14. Survival

15. Negotiations and Reset

16. Inpatient Services

17. Outpatient Program

18. Outpatient Services

19. Education and Admin Services • All day ELNEC course twice per year • Grand Rounds once per year • New Nurse Residency Lecture quarterly • Unit-based inservices PRN • Nursing Grand Rounds twice per year • Provider Wellness Committee • Hospitalist Journal Club twice per year • Ad-hoc committees needing palliative care input PRN • Monthly Section Head Meetings

20. Self-Care

21. Results 2018-19

22. Satisfaction Survey • Hospitalist surveyed annually via Survey Monkey • Satisfaction Survey mailed to everyone seen by palliative care with a current address in the system (exception for complicated cases) • 31% response rate • Utilize survey from CAPC • Anonymous • Likert Scale (Strongly Agree through Strongly Disagree • Provider named

23. Satisfaction Results • Dr. Owens was respectful and professional: 97% SA, 3% A • We were able to talk about goals and preferences of care: 87% SA, 11% A, 2% Somewhat Agree • Dr. Owens helped us feel more comfortable (examples: decreased pain, help with breathing, improved nausea, less stress): 80% SA, 15% A, 3% Somewhat Agree, 2% Disagree • Dr. Owens helped coordinate care when needed: 79% SA, 19% A, 2% Somewhat agree • The educational material was helpful and easy to read: 72% SA, 21% A, 7% Somewhat agree • I am satisfied with the Supportive Care provided by Dr. Owens: 84% SA, 14% A, 1% Somewhat Agree, 1% Disagree • High level of satisfaction from Hospitalist Group

24. PEARLS • It is possible to provide excellent Palliative Care without a full team • We should always strive towards the gold standard, it is a nice goal • Smaller programs in general don’t lend themselves well to new graduates, inexperienced practitioners from any discipline, or fellows new to attending practice • The model described here is NOT for everyone or every institution • There is no “set” model, explore what works for your institution (the various discipline combinations is almost limitless), know what works best for your institution • SURVEY YOUR PATIENTS, FAMILIES, AND CUSTOMERS, CHANGE AS NEEDED