Promoting excellence in end-of-life care: A report on innovative models of palliative care
ABSTRACT Promoting Excellence in End-of Life Care, a national program of The Robert Wood Johnson Foundation, funded 22 demonstration projects representing a wide range of health care settings and patient populations to develop innovative models for delivering palliative care that addressed documented deficiencies in the care of patients and families facing the final stage of life.
To determine the practicality (feasibility of development and operation as well as acceptance by stakeholders) of new models of care and to determine the impact of the models on access to, quality of and financing for palliative care.
The program cannot report scientifically rigorous outcomes, but the grant-funded projects used a variety of methods and measures to assess acceptance of new models and their impact from the perspectives of various stakeholders, including patients and their families, clinicians, administrators and payers. While it is not possible to aggregate data across projects, the data reported to the Promoting Excellence national program office were used to describe program impact with respect to the practicality of palliative care service integration into existing clinical care settings (feasibility and acceptance by stakeholders), the availability and use of palliative care services (access), quality of care (conformance to patient expectations and accepted clinical standards) and costs of care.
The 22 projects provided services in urban as well as rural settings, in integrated health systems, hospitals, outpatient clinics, cancer centers, nursing homes, renal dialysis clinics, inner city public health and safety net systems and prisons. Populations served included prison inmates, military veterans, renal dialysis patients, Native Americans, Native Alaskans, and African American patients, inner-city medically underserved patients, pediatric patients, and persons with serious mental illness patients.
Hosting or adopting institutions sustained or expanded twenty of the 22 models, and feedback from all stakeholders was positive. Project sites developed and utilized new palliative care services and addressed quality through implementation of new standards and clinical protocols. Costs of care, where they could be assessed, were unaffected or decreased for project patients versus historical or concurrent controls.
The 22 Promoting Excellence in End-of Life Care projects demonstrated that by individualizing patient and family assessment, effectively employing existing resources and aligning services with specific patient and family needs, it is possible to expand access to palliative services and improve quality of care in ways that are financially feasible and acceptable to patients, families, clinicians, administrators, and payers.
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ABSTRACT: Palliative care has been one of the most rapidly growing fields of health care in the United States in the past decade. The benefits of palliative care have now been shown in multiple clinical trials, with increased patient and provider satisfaction, equal or better symptom control, more discernment of and honoring choices about place of death, fewer and less intensive hospital admissions in the last month of life, less anxiety and depression, less caregiver distress, and cost savings. The cost savings come from cost avoidance, or movement of a patient from a high cost setting to a lower cost setting. Barriers to expanded use include physician resistance, unrealistic expectations of patients and families, and lack of workforce. The future of palliative care includes more penetration into other fields such as nephrology, neurology, and surgery; further discernment of the most effective and cost-effective models; and establishment of more outpatient services.Annual Review of Public Health 03/2014; 35:459-475. DOI:10.1146/annurev-publhealth-032013-182406 · 6.63 Impact Factor
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ABSTRACT: Older adults with advanced metastatic lung cancer are faced with both poor prognosis and options for cancer-directed therapies very late into their disease trajectory. This trend of increasing chemotherapy close to death in older cancer patients continues to grow resulting in unmet psychosocial and existential needs at the end-of-life for patients who choose to continue cancer-directed therapies. The present study is grounded in an existential and social constructionist perspective which characterizes the either/or choice of late-stage cancer treatment or palliative care through a hospice program as an existential conflict within a context of socially constructed options for end-of-life care. This observational study examined differences among three groups of older advanced lung cancer patients (N = 30) to determine whether simultaneous care patients have better psychosocial and existential quality-of-life at the end-of-life than patients receiving only cancer-directed therapy or routine hospice care. Simultaneous care refers to a care model in which patients with late-stage cancer receive cancer-directed therapy and routine hospice services concurrently. Quality-of-life at the end-of-life represents developmental tasks and concerns associated with preparation for death and life closure. Participants were recruited from a Veterans Affairs Medical Center oncology clinic and a non-profit community hospice. Nonparametric statistics examined the study’s primary hypothesis whether simultaneous care makes a difference in quality-of-life at the end-of-life compared to conventional care models such as cancer-directed therapy or routine hospice care. The primary hypothesis was not supported in the present study, although subgroup analyses based on demographic variables indicated statistically significant results. These findings support a sense of generativity, interpersonal connection, and having social support in which one can communicate substantial concerns or thoughts as important components of life closure. Methodological challenges within the present study reify cultural influences embedded in oncology practice and society as a whole that continue to support a taboo around dying and death. Efforts to integrate a hospice care model and cancer-directed therapy earlier in a cancer diagnosis face considerable challenges as a result of socially-constructed meanings of hospice. Further study is needed to determine which palliative care models can best meet the psychosocial and existential needs of older advanced lung cancer patients at varying points on the cancer trajectory.
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ABSTRACT: This paper focuses on the sustainability of existing palliative care teams that provide home-based care in a shared care model. For the purposes of this study, following Evashwick and Ory (2003), sustainability is understood and approached as the ability to continue the program over time. Understanding factors that influence the sustainability of teams and ways to mitigate these factors is paramount to improving the longevity and quality of service delivery models of this kind. Using qualitative data collected in interviews, the aim of this study is twofold: (1) to explore the factors that affect the sustainability of the teams at three different scales, and; (2) based on the results of this study, to propose a set of recommendations that will contribute to the sustainability of PC teams. Sustainability was conceptualized from two angles: internal and external. An overview of external sustainability was provided and the merging of data from all participant groups showed that the sustainability of teams was largely dependent on actors and organizations at the local (community), regional (Local Health Integration Network or LHIN) and provincial scales. The three scales are not self-contained or singular entities but rather are connected. Integration and collaboration within and between scales is necessary, as community capacity will inevitably reach its threshold without support of the province, which provides funding to the LHIN. While the community continues to advocate for the teams, in the long-term, they will need additional supports from the LHIN and province. The province has the authority and capacity to engrain its support for teams through a formal strategy. The recommendations are presented based on scale and in priority order to better illustrate how actors and organizations could move forward. This study may inform program and policy specific to strategic ways to improve the provision of team-based palliative home care using a shared care model, while simultaneously providing direction for team-based program delivery and sustainability for other jurisdictions.BMC Palliative Care 08/2013; 12(1):32. DOI:10.1186/1472-684X-12-32 · 1.79 Impact Factor