PCQN Forum Steven Pantilat, MD Kara Bischoff, MD Angela Marks, MSEd PCQN Conference May 3, 2018
PCQN 111 Member Organizations 69 Community Hospitals 14 Academic Hospitals 11 Public Hospitals 17 Community-Based Orgs
PCQN Member Hospital Size Percent (%) 50 45 40 35 30 25 20 15 10 5 0 14.5 29.1 29.1 Mean= 379 bed Median= 333 beds Range: 48-1126 48-149 150-299 300-499 500+ Number of beds 27.3
Annual Inpatient Census
Patient Discharges for PC teams with 3 4.9 FTE
Patient Discharges by Weekend Coverage
Funding Support* 100 94.4 80 Percentage (%) 60 40 42.3 25.4 25.4 54.6 20 0 Hospital Hospital in-kind Philanthropy Grants Hospice Funding Professional fee billing Funding Sources 5.6 1.4 None *: Multiple sources of funding could be selected
Inpatient Palliative Care Service Availability 100 99 Percentage (%) 80 60 40 20 0 45 40 41 33 28 26 29 22 25 11 1 0 0 0 0 Weekday (9-5) Weekend (9-5) Weekday nights Weekend nights Time of the Week Onsite Able to return Telephone only No Coverage
Inpatient PC Service Team Meetings 80 60 64 Percentage (%) 40 20 13 14 0 Daily Several times a week 1 Weekly Every other week Monthly or less frequently Frequency of PC team meetings 3 4 No meetings
Staffing Discipline Number of staff FTE Credentialed Chaplain 0.8 0.4 0.3 Social Worker 1.2 1.0 0.5 Registered Nurse 1.2 1.0 0.8 Nurse Practitioner 1.3 1.1 0.9 Physician 2.7 1.4 2.7 3 + Disciplines 84% Mean FTE Median FTE FTE Range: Chaplain, SW, RN, NP, MD 4.2 3.4 0.5 17.6 Nurse, MD 3.0 2.3 0.3 11.9 Mean Median Range: Staff/100 beds* 2.3 1.8 0.7 10.4 *: Chap., SW, RN, NP, MD
Hospital Size, Staffing* & FTE/100 beds Hospital Size n Mean p Hospital size FTE/100 beds 0.1 48 149 beds 8 1.5 150 299 beds 15 1.4 300 499 beds 16 1.1 500+ Beds 14 1.0 *: Chap., SW, RN, NP, MD
PCQN Data Community-Based: est. 2017 Teams: 31 >10,000 visits, >3,500 patients 2,095 reports Inpatient: 2013 Teams: 86 >140,000 patient encounters 45,945 reports
PCQN Inpatient Database Year Patient records 2013 5,400 2014 9,917 2015 20,758 2016 41,921 2017 53,813
Reasons for Consult: 2017 Reason Community Inpatient Goals of care 39% 73% Pain management 57% 17% Symptom management 51% 13% Support for patient/family 36% 24% Cancer Diagnosis Community: 68% Inpatient: 29% PPS Clinic: 69% Home: 51% Inpatient: 35%
Community Data: 2017 2,729 patients 8,101 visits 3/pt Clinic 58% Home 34% Telehealth 9% Referral source Outpatient specialist: 47% Primary care: 11% Inpatient PC: 11% % seen within 14 days of referral: 60%
Advance Care Planning Outcome Community Inpatient Advance directive on chart 33% 14% POLST complete (not full code) 71% 64%
Community Based
26%
Inpatient Pain Scores 28% 40% of patients able to report, have moderate/severe pain
Inpatient Pain Improvement
Community Based Outcomes
PCQN Publications Vol. 55 No. 3 March 2018 Journal of Pain and Symptom Management 881 Original Article Identifying Opportunities to Improve Pain Among Patients With Serious Illness Kara E. Bischoff, MD, David L. O Riordan, PhD, Kristyn Fazzalaro, LCSW, Anne Kinderman, MD, and Steven Z. Pantilat, MD Palliative Care Program (K.B., D.L.O., A.K., S.Z.P.), University of California, San Francisco, San Francisco, California; Hoag Memorial Hospital Presbyterian (K.F.), Newport Beach, California; and San Francisco General Hospital (A.K.), San Francisco, California, USA Abstract Context. Pain is a common and distressing symptom. Pain management is a core competency for palliative care (PC) teams. Objective. Identify characteristics associated with pain and pain improvement among inpatients referred to PC. Methods. Thirty-eight inpatient PC teams in the Palliative Care Quality Network entered data about patients seen between December 12, 2012 and March 15, 2016. We examined patient and care characteristics associated with pain and pain improvement. Results. Of patients who could self-report symptoms, 30.7% (4959 of 16,158) reported moderate-to-severe pain at first assessment. Over 40% of these patients had not been referred to PC for pain. Younger patients (P < 0.0001), women (P < 0.0001), patients with cancer (P < 0.0001), and patients in medical/surgical units (P < 0.0001) were more likely to report pain. Patients with pain had higher rates of anxiety (P < 0.0001), nausea (P < 0.0001), and dyspnea (P < 0.0001). Sixty-eight percent of patients with moderate-to-severe pain improved by the PC team s second assessment within 72 hours; 74.7% improved by final assessment. There was a significant variation in the rate of pain improvement between PC teams (P < 0.0001). Improvement in pain was associated with improvement in anxiety (OR ¼ 2.9, P < 0.0001) and dyspnea (OR ¼ 1.4, P ¼ 0.03). Patients who reported an improvement in pain had shorter hospital length-of-stay by two days (P ¼ 0.003). Conclusion. Pain is common among inpatients referred to PC. Three-quarters of patients with pain improve and improvement in pain is associated with other symptom improvement. Standardized, multisite data collection can identify PC patients likely to have marked and refractory pain, create benchmarks for the field, and identify best practices to inform quality improvement. J Pain Symptom Manage 2018;55:881e889.! 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved. Key Words Palliative care, pain, quality improvement, prevalence Background Pain is a common and distressing symptom in hospitalized, seriously ill patients and those who referred 1e9 a common reason for inpatient PC consultation, and it is a core competency for PC teams.11e15 Even when pain is not the primary reason for PC consultation, it is often necessary to control pain before being
Going Mainstream Strategic initiative alignment Need and opportunity Benchmarks QI, safety, value Funding stream and requests Director stipend Interdisciplinary team Reporting Committee membership Common metrics Leadership
Quality Improvement in the PCQN Kara Bischoff, MD Director of Quality Improvement, PCQN
Our QI Menu QI collaboratives Strategy exchange: conferences & longitudinal Outpatient data collection & program development Case reviews Practical QI education Partnering with AAHPM/HPNA QI Education Committee Support for local QI projects 5/2/18 26
QI Collaboratives Pain POLST Surrogate Decision Maker Spiritual Screening Anxiety Screening & Improvement Timely Access to PC
Timely Access to PC Inpatient: % of PC patients with first PC visit within 3 days of hospital admit Mean # days between hospital admission and first PC visit Outpatient: % of PC patients with initial PC visit within 14 days of referral Median # days between referral and initial PC visit
QI Framework: PDSA Cycle
SMART Goals Specific Measurable Achievable Relevant Time bound Example: Increase the % of PC patients seen within 3 days of hospital admission from 61% to 71% by November 1, 2018.
Patients - too sick - don t see value/reason - forget appointment - too many other appts - transportation difficulties Providers awareness of: - Oncology-Plus - benefits of palliative care - how to refer ZSFG - when to refer/criteria - Multiple ways to refer - Providers don t have required info when placing referral - No consistent screening for need - Hard to find ereferrals - Limited clinic slots available - Multiple EHR s - Currently can only see patients in clinic Limited resources for: - Support staff - Clinic space - Perception that Palliative Care = EOL care - Different platforms for charting
Process Map Inpatient Televisits New Referral Contact Oncologist Contact/ Schedule Patient Reminder calls Patient seen in clinic Outpatient Review Review SW calls
Barriers à Opportunities for Improvement Trauma patients referred to PC late Trauma-PC working group meeting to identify PC needs, particularly among frail patients with hip fracture Pts followed intensively in outpt PC don t receive timely inpt PC Process to identify outpt PC pts who are admitted and consider need for inpt PC
Adopt, Adapt or Abandon Not all tests of change are appropriate for Standard Work A successful test of change will lead to either: Adoption Adaptation, or Abandonment! Example: Outpt PC Team Inpatient PC Team Primary Team (e.g. Hospitalist)
Inpatient QI Collab Participants: Patients seen within 3 days of admission 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 49.9% 46.9% 48.2% 60.7% Baseline January February March
Inpatient QI Collab Participants: Patients seen within 3 days of admission 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 100% 100% 100% 59% 64% 65% 59% 50% 50% 52% 46% 41% 36% 0% 0% 0% Team A Team B Team C Team D Baseline January February March
Outpatient QI Collab Participants: Patients w/ initial visit within 14d of referral 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 49.7% 46.7% 75.0% 75.6% Baseline January February March
Outpatient QI Collab Participants: Patients w/ initial visit within 14d of referral 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 100% 100% 83% 80% 75% 76% 77% 67% 54% 33% 38% 27% 29% 14% 0% Team A Team B Team C Team D Baseline Janurary February March
Quality Improvement Pearls Choose a goal you care about, align with institutional priorities Identify engaged and dedicated champion(s) Engage relevant stakeholders in improvement work Track data regularly, make it visible Make the system work for you Garner support from other services who share your goals
Participation in the PCQN QI Collaborative has helped... educate my team about QI à 16/17 agree motivate my team to engage in QI à 15/17 agree my team be more successful in our QI efforts à 16/17 agree
Next QI Collaborative Project: Caregiver Assessment & Intervention Funded, intensive, longitudinal QI project to improve assessment of and support for family caregivers Goal is for 6-10 PCQN teams to develop an assessment tool and brief interventions for caregivers in a way that is meaningful & feasible
Next Steps BI-MONTHLY CALLS Timely access to PC QUARTERLY CALLS Pain, POLST, SDM, Spiritual, Anxiety PLANNING Caregiver Assessment & Intervention
Our QI Menu QI collaboratives Strategy exchange: conferences & longitudinal Outpatient data collection & program development Case reviews Practical QI education Partnering with AAHPM QI Education Committee Support for local QI projects 5/2/18 49
Thank you! Questions? Kara.Bischoff@ucsf.edu Angela.Marks@ucsf.edu
PCQN Updates PCQN Forum Spring Conference May 3, 2018
1. Monthly Educational Webinars Palliative Liver Clinic - Group Visit Model (LAC +USC) Interdisciplinary Synergy: Navigating Collaborative Culture and Accountability (Hospice of Santa Cruz) Cancer Immunotherapy: Everything you ve wanted to know (UCSF) 2. Longitudinal Learning Cultivating Resiliency Skills
Data Registry Updates Optional Data Elements: Date of First Contact Coming Soon: Customizable optional data elements Variables in Reports: Total # of patients with AD or POLST Symptom improvement (D1 D2 & First Last) in all reports
Data Registry Updates New Reports: Summary of Optional Items (CB) Symptom Improvement (CB)
Security Updates Password change every 6 months (can t reuse) 180 days of inactivity suspended 30 days to log-in upon reactivation 360 days of inactivity purged from database Contact: support@pcqn.org (pcqnsupport@ucsf.edu)
EHR Integration
Quality Measurement/Improvement Collaborative Multiple registries in a small field Our vision is grand Limited by resources and staffing Challenging to be great at everything Build a better database Easier EHR integration Quicker response to changing IT needs Pay for performance capability Revise dataset By us, for us 58
Quality Measurement/Improvement Collaborative Completed Yearlong process to explore collaboration PCQN GPCQA CAPC AAHPM Insights Our field needs a single, quality measurement/improvement solution Patient-level outcome data collection is feasible and important Everyone should participate 59
PCQN- We! Proof of concept Evidence of value to teams and the field Demonstration of benefit and effectiveness Recognized nationally and internationally for our work together If you want to fast, go alone If you want to go far, go together 60
Quality Measurement/Improvement Collaborative Commitment to move forward together Benefits outweigh the risks Only way to achieve the vision for PCQN and the field Create one organization Leadership from PCQN, GPCQA, CAPC, AAHPM Two years to a new database and organization From when we start Cores to create a community and maintain essential elements Practice Improvement- PCQN Research- GPCQA Technical Assistance- CAPC 61
Quality Measurement/Improvement Collaborative PCQN will be at the core of the national quality measurement/improvement collaborative Enshrines and extends our work together Embraces strengths of each partner to create a whole that is greater than the sum of its parts Next steps Grant from Moore Foundation in process Engage our work teams and Advisory Board Help to lead the process 62
Our Commitment Our members Our community Our values Our approach PC Field Institution PCS Team Clinician Patient and Family 63
A (more) Magic Trip Gonna need a bigger bus! If you want to go fast, go alone If you want to go far, go together African proverb