Training the Next Generation of Hospice Clinicians in NYC: Findings and Outcomes from Restructured VNSNY Hospice Fellowship Program

Transcription

1 Training the Next Generation of Hospice Clinicians in NYC: Findings and Outcomes from Restructured VNSNY Hospice Fellowship Program

2 Objectives Identify key concepts for developing and launching new hospice fellowship programs and/or improving existing hospice fellowship programs Describe mutually beneficial relationships among fellows, the host program, and the fellowship site 2

3 The VNSNY Hospice Fellowship Training Program Began in 2004 with 2-week rotations for six fellows from two hospitals, structured as scheduled, observational experience with hospice physicians, nurses, social workers, and spiritual care counselors NOW ( academic year): 45 interdisciplinary fellows (38 physicians, 6 NPs, one Doctoral Pharmacist) from eight NYC academic medical centers with rotations lasting up to three months, structured as embedded interdisciplinary team member experience 3

4 The VNSNY Hospice Fellowship Training Program I. Fellowship Education Content and Measurement (2004-present) II. Fellowship Program Format / Structure Observership Model Transition Year (January Embedded Team Member Model Launch) Pilot Year - Embedded Team Member Model (first full academic year) Embedded Team Member Model (second full academic year) Embedded Team Member Model (current academic year) 4

5 Fellowship Education Content and Measurement (2004 Present) Partner programs submit learning objectives with fellowship agreement based on ACGME Educational Program required competencies and skills. Patient Care and Procedural Skills Practice-based Learning and Improvement Professionalism Medical Knowledge Interpersonal and Communication Skills Systems-based Practice ACGME requirement: Physician fellows are required to make at least 25 home visits Mandatory day-long orientation at start of each academic year and didactics throughout year (starting with academic year)* Fellows are evaluated by discipline-specific preceptor (online evaluation submission credentials sent to preceptor by host program coordinator) Fellows report their learning and growth and provide feedback regarding VNSNY Hospice Rotation experience via prerotation and post-rotation surveys Starting May 2015, periodic meetings (typically mid- and end-of-year) with partner PDs for planning, feedback, and input *See Appendix for sample didactics schedule. 5

6 VNSNY Hospice Fellowship Didactics Curriculum Date Orientation Day Title Role of Hospice Medical Director Hospice Overview: Eligibility, LCDs, CT Is, F2Fs Bereavement Social Work Spiritual Care Services Specialty Program: Veterans 12/7/16 (before holiday party) 2/14/17 (70th Street) 4/18/17 (70th Street) Dementia in Hospice Last hours of living / symptom management at the end of life Wound Care at Home Methadone at Home Hospice Psychopharmacology Pediatrics ongoing Specialty Program: Cardiac Care 6

7 Pre-Rotation and Post-Rotation Surveys* Fellows self-evaluate familiarity with the following hospice care administrative concepts prior to and after their rotations Medicare Hospice Benefit LCDs (Local Coverage Determinations) Levels of care for hospice patients Regulatory responsibilities of a hospice physician Certification and recertification process Fellows self-evaluate knowledge of and comfort with the following hospice home care clinical concepts prior to and after their rotations Issues in caring for dying patients at home Role of family in the care of patients dying at home Role of hospice physician and other disciplines (nursing, spiritual care, social work, etc.) in the care of patients dying at home Their comfort with caring for patients dying in the home Symptom management in the home at EOL Fellows share individual rotation goals and whether they are met; provide free form feedback regarding best and worst aspects of rotations; offer suggestions for improvement to rotations; and report how VNSNY Hospice rotations affect their future professional goals. *See Appendix for sample pre- and post-rotation surveys from academic year. 7

8 Fellowship Program Format / Structure Observership Model Transition Year (January Embedded Team Member Model Launch) Pilot Year - Embedded Team Member Model (first full academic year) Embedded Team Member Model (second full academic year) Embedded Team Member Model (current academic year) 8

9 Fellowship Format: PRIOR MODEL ( ) Observership Model Centralized scheduling: o Coordinator responsible for scheduling for all fellows recruits staff clinicians for joint visits from pool of interdisciplinary team staff preceptors o Fellows visits based in one borough (when possible) but not one team as scheduling depended on availability of individual staff preceptors o Coordinator-organized schedules* sent on a weekly basis (sometimes day-to-day if difficult to secure staff preceptor for visits ahead of time) Fellow role unclear: Fellows observe and advise on joint visits; NO independent visits; NO access to EMR Limited access to staff physicians for ongoing teaching and supervision; NO single assigned supervisor to complete rotation evaluations No built-in continuity as re: patient care, supervision, and team involvement *See Appendix for sample week schedule for observership model 9

10 Sample Week: Observership Model Rotation Schedule* *Fictional names and phone numbers 10

11 Pre- and Post-Rotation Survey Results* Observership Model Hospice Care Administrative Concepts * Final full academic year of observership model. 11

12 Pre- and Post-Rotation Survey Results* Observership Model Hospice Home Care Clinical Concepts * Final full academic year of observership model. 12

13 Post-Rotation Feedback Summary Over 89% of fellows report being more or much more familiar, knowledgeable, and/or comfortable with most hospice administrative and clinical care concepts after completing VNSNY Hospice rotation. Reported best aspects of rotation: interdisciplinary team approach, VSNY Hospice staff, diversity of cases and patient population A sample of responses regarding areas of improvement: Observership Model o More clinical responsibility for fellows o It would be better to have a few people to rotate with. Having a new person every day was difficult. I found working with the same person multiple times through the month was more effective. There was opportunity for continuity of care. o allow fellows to have a more active role in decision making and shadowing MDs to understand symptom management, o It will be better to have to opportunity to round [with] the same nurses to follow up [with] the patient Moreover, spending more days with a hospice physician will be more comprehensive. o More time with MD doing clinical care o Recommend a reading list; Add didactics! 13

14 TRANSITION YEAR Year split between Observership and Embedded Team Member Model o July December 2014 > Observership Model o January June 2015 > Embedded Team Member Model o Fellows rotate under observership model, embedded team member model, or BOTH Pre- and post-rotation survey fellow-reported mastery of hospice administrative and clinical care concepts consistent with previous years Free form post-rotation feedback echoes suggestions for improvement o more active involvement in home visits than being [an] observer. More learning by staying with 1 interdisciplinary team than changing very frequently o I would suggest that each fellow should be assigned to one team and follow the same patients to see the progress of their disease process. o more hands on responsibility for fellows as they mature through their fellowship, more patient ownership for the month of rotations o Computer access, it was very difficult to work cases blindly Two fellows report that embedded team member is improvement over observership model 14

15 RATIONALE FOR CHANGE Need for more depth of experience and learning (including interdisciplinary team process) Need for improved engagement of trainees Physician-trainee / fellow service to patients and families allows team members to devote time and resources to trainee as part of patient s care Ability to monitor, mentor, and assess competence and additional training needs over time De-centralization of scheduling to geographic hospice teams and team members as a responsibility of physician-trainee / fellow decreases central administrative burden and makes scheduling, time management, and team communication important learning 15

16 Development, implementation, roll out of restructure (embedded team member model): Due diligence, input from, and collaboration with multiple departments Senior Leadership Legal HR College Relations IT Compliance Partner Program Directors Buy in from hospice medical staff (physicians and NPs who will be fellow preceptors / supervisors) Protocol and procedures for credentialing and onboarding to clear fellows medically and legally to see patients as fully functioning clinicians / embedded team members Onboarding includes background checks and completion of VNSNY staff compliance trainings VNSNY staff IDs Access to and EMR training for patient documentation Issuing staff computer and phone for HIPAA compliant patient communications 16

17 RESTRUCTURE: Embedded Team Member Model Launched January 2015 (mid academic year) / first full academic year Each fellow embedded on ONE team (w/ ONE preceptor) for full (typically) 4-6 week rotation block Fellow rotation requirements* distributed with team placement . Fellows expected to: Participate fully as embedded team member Attend weekly IDT meetings Coordinate their own schedules with preceptor and HTM (Hospice Team Manager) Make joint interdisciplinary and independent patient visits Fulfill ACGME 25 home visit requirement Fellows required to document all visits in EMR and all activity (patient visits, weekly IDT, clinic, etc.) on personalized patient log template* and submit to coordinator for weekly review Fellows offboard (submit final patient log, return staff ID and equipment) after each rotation block (and onboard again if they return to us) *See Appendix for Rotation Requirements and Patient Log Template 17

18 As a Physician Fellow, you are assigned to a regional team for each 4-6 week rotation. During your rotation, we expect you to participate as fully as possible in regular team activities including Evaluating and developing treatment recommendations for patients Presenting such patient evaluations and recommendations to the attending physician or NP Participating in weekly Interdisciplinary Group (IDG) meetings Participating in home visits with other team members including nurses, SWs, SCCs, etc. For each rotation block, presentation at IDT subject to be agreed upon with preceptor You will work directly with the Hospice Team Manager (HTM) and Regional Hospice Medical Director (HMD) to coordinate your weekly schedule and to determine priorities on a day-to-day basis. Per ACGME requirements, you will be responsible for scheduling and notating 25 home visits to hospice patients. We recommend that, as a part of these visits you accomplish: At least ten (10) medical evaluations presented to attending physician in your region At least five (5) home visits with hospice nurse At least five (5) home visits with a spiritual care counselor At least five (5) home visits with a social worker Rotation Requirements: Home Visit Rotation (typically 4-6 weeks) IMPORTANT DOCUMENTATION AND COMMUNICATION NOTICE: ALL PATIENT VISITS MUST BE DOCUMENTED IN SUNCOAST (EMR) All notes must be signed and locked WITHIN 24 HOURS OF THE PATIENT CONTACT/VISIT. At the end of each week: Coordinator your updated schedule of patient visits including: o Date, then patient first and last initials, then EMR (Suncoast) numbers o Type of visit (Nurse, SW, Spiritual Care, etc.) o Name (first & last) of joint visit clinician(s) (when applicable) Patient logs must be ed via VNSNY staff in order to be HIPAA compliant. (Encrypted s from hosting institutions are also HIPAA compliant.) At the end of each of your rotation blocks, return VNSNY staff ID and equipment to Coordinator (unless special arrangement is made otherwise). If you have multiple rotation blocks, complete the post-rotation survey (sent to your host program via Survey Monkey) at the end of your final rotation block. Below is a recommended timeline to ensure that you complete all required visits. Week 1: At least 5 visits by the end of week 1 Week 2: At least 12 visits by the end of week 2 Week 3: At least 20 visits by the end of week 3 Week 4: At least 25 visits by the end of week 4 18

19 Embedded Team Member Model Schedule / Patient Log Template: 19

20 Findings and Outcomes from Pilot Year first full academic year of restructure PRE- and POST-ROTATION SURVEY RESULTS Hospice Care ADMINSTRATIVE Concepts 20

21 Findings and Outcomes from Pilot Year first full academic year of restructure PRE- and POST-ROTATION SURVEY RESULTS Hospice HOME CARE CLINICAL Concepts 21

22 Findings and Outcomes from Pilot Year first full academic year of restructure HIGHLIGHTS On post-rotation survey, appx 79% of fellows stated that best aspects of rotations were autonomy and independence with scheduling and managing patients and/or HMD preceptors and interdisciplinary team staff. Three fellows join VNSNY Hospice permanent medical staff as full-time and per diem medical directors Physician fellows log over 1,500 joint and independent patient visits* First fellow placement with HOPE (Harlem Outreach) Team = SUCCCESS First end-of-academic-year meeting with partner program directors for feedback and input regarding first full year of restructure and planning upcoming year *SOURCE: Fellows Visit Tally (Internal Record) 22

23 Findings and Outcomes from PRE- and POST-ROTATION SURVEY RESULTS Hospice Care ADMINSTRATIVE Concepts 23

24 Findings and Outcomes from PRE- and POST-ROTATION SURVEY RESULTS Hospice HOME CARE CLINICAL Concepts 24

25 Findings and Outcomes from HIGHLIGHTS On post-rotation survey, the best aspects of the rotation, as reported by fellows, generally fell into one of the following categories: autonomy in scheduling and managing patients, direct hands on patient care, feeling like an important player on team, spectrum / variety of patient population, and interdisciplinary team approach and staff. Interdisciplinary fellows (PharmD, SW) added to cohort and curriculum development for each discipline Two physician fellows joined VNSNY Hospice permanent medical staff Fellow involvement with VNSNY Hospice Specialty Programs (HOPE, Veterans Outreach, Cardiac Care) increases and expands Formal didactics curriculum* launched (included revamped Orientation Day curriculum* as didactics launch) Mount Sinai fellow high acuity patient QI project leads to reduction in team rehospitalizations intervention replicated and piloted as VNSNY Hospice standard practice with Queens teams in January 2018 * See Appendix for didactics curriculum and 2017 Orientation Agenda 25

26 Pre- and Post-Rotation Survey Results* Hospice Care Administrative Concepts * PRELIMINARY DATA: Post-rotation data as of 3/15/18. 26

27 Pre- and Post-Rotation Survey Results* Hospice Home Care Clinical Concepts * PRELIMINARY DATA: Post-rotation data as of 3/15/18. 27

28 Findings and Outcomes from (to date): To date feedback from fellows and partner program directors is generally favorable and consistent with previous years Current Bronx VA fellow (already!) joining VNSNY Hospice permanent medical staff as regional team physician (July 2018) Home hospice curriculum developed for PharmD fellow Fellows involvement with VNSNY Hospice Specialty Programs continues to increase and expand Expansion of Mount Sinai fellow high acuity intervention to VNSNY Hospice standard practice > currently being piloted with fellows placed with VNSNY Hospice Queens teams 28

29 Benefits of Restructure Embedded Team Member Model SUMMARY Improvement over observership model Robust clinical training experience Fellows report mastery of hospice administrative concepts and increased aptitude / comfort with providing EOL care Self-guided scheduling, autonomy and independence Direct, hands on patient care Self-guided patient management and continuity of care Continuity in teaching and supervision (one supervising preceptor) Significant contribution to IDT Self-guided learning objectives Ever increasing reach and influence of fellows as re: patient care and quality improvement VNSNY Hospice Staff benefits (includes mutual benefit / reciprocity between staff and fellows) PATIENTS AND FAMILIES BENEFIT! 29

30 30

31 Thank you! Contributors: John Delfs, MD Shannon Harris, MA Rosemary Baughn, MSN, RN Richard Dundy, MD Ritchell Dignam, MD 31

32 Appendix 32

33 VNSNY Hospice Fellowship Didactics Curriculum Date Orientation Day Title Role of Hospice Medical Director Hospice Overview: Eligibility, LCDs, CT Is, F2Fs Bereavement Social Work Spiritual Care Services Specialty Program: Veterans 12/7/16 (before holiday party) 2/14/17 (70th Street) 4/18/17 (70th Street) Dementia in Hospice Last hours of living / symptom management at the end of life Wound Care at Home Methadone at Home Hospice Psychopharmacology Pediatrics ongoing Specialty Program: Cardiac Care 33

34 VNSNY Hospice Pre-Rotation Survey* * Via Survey Monkey 34

35 VNSNY Hospice Post-Rotation Survey* *via Survey Monkey 35

36 Sample Week: Observership Model Rotation Schedule* *Fictional names and phone numbers 36

37 As a Physician Fellow, you are assigned to a regional team for each 4-6 week rotation. During your rotation, we expect you to participate as fully as possible in regular team activities including Evaluating and developing treatment recommendations for patients Presenting such patient evaluations and recommendations to the attending physician or NP Participating in weekly Interdisciplinary Group (IDG) meetings Participating in home visits with other team members including nurses, SWs, SCCs, etc. For each rotation block, presentation at IDT subject to be agreed upon with preceptor You will work directly with the Hospice Team Manager (HTM) and Regional Hospice Medical Director (HMD) to coordinate your weekly schedule and to determine priorities on a day-to-day basis. Per ACGME requirements, you will be responsible for scheduling and notating 25 home visits to hospice patients. We recommend that, as a part of these visits you accomplish: At least ten (10) medical evaluations presented to attending physician in your region At least five (5) home visits with hospice nurse At least five (5) home visits with a spiritual care counselor At least five (5) home visits with a social worker Rotation Requirements: Home Visit Rotation (typically 4-6 weeks) IMPORTANT DOCUMENTATION AND COMMUNICATION NOTICE: ALL PATIENT VISITS MUST BE DOCUMENTED IN SUNCOAST (EMR) All notes must be signed and locked WITHIN 24 HOURS OF THE PATIENT CONTACT/VISIT. At the end of each week: Coordinator your updated schedule of patient visits including: o Date, then patient first and last initials, then EMR (Suncoast) numbers o Type of visit (Nurse, SW, Spiritual Care, etc.) o Name (first & last) of joint visit clinician(s) (when applicable) Patient logs must be ed via VNSNY staff in order to be HIPAA compliant. (Encrypted s from hosting institutions are also HIPAA compliant.) At the end of each of your rotation blocks, return VNSNY staff ID and equipment to Coordinator (unless special arrangement is made otherwise). If you have multiple rotation blocks, complete the post-rotation survey (sent to your host program via Survey Monkey) at the end of your final rotation block. Below is a recommended timeline to ensure that you complete all required visits. Week 1: At least 5 visits by the end of week 1 Week 2: At least 12 visits by the end of week 2 Week 3: At least 20 visits by the end of week 3 Week 4: At least 25 visits by the end of week 4 37

38 Embedded Team Member Model Schedule / Patient Log Template: 38