An Extra Layer of Outpatient

Support: Lessons Learned from

a “Without Walls” Palliative Care

Program

Leanne Yanni, MD

Medical Director, Palliative Medicine Bon Secours Virginia

Health System

January 22, 2015

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An Extra Layer of Outpatient

Support: Lessons Learned from

a “Without Walls” Palliative Care

Program

Leanne Yanni, MD

Medical Director, Palliative Medicine Bon Secours Virginia

Health System

January 22, 2015

Objectives

➔ Examine the structure of a “without walls”

outpatient palliative care program

➔ List quality end of life measures that may be

achieved as a result of outpatient palliative care

➔ Identify specific challenges faced in the first 2

years of program development

➔ Apply lessons learned while developing your own

outpatient program

4

Bon Secours

Virginia Health System ➔ Catholic Health System

➔ Medical Group

– Operates Physician Practices, Home

Health, and Hospice across Virginia

– >600 providers; >165 locations

– Accountable Care Organization

➔ Palliative Medicine is a specialty practice

within the Medical Group

➔ 3 of 4 Richmond Hospitals TJC Certified

(Advanced Certification for Palliative Care)

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Conduct

Needs

Assessment

Why?

Vision

➔A dynamic multi-faceted Palliative Medicine practice that provides care

without walls to meet the needs of patients with serious illness

Align Vision with Health System Priorities

➔Mission to care for the “poor and dying”

➔Accountable Care Organization

➔Enhance quality / reduce cost

“Provider Conscience”

➔If we had just seen this patient before they were admitted.

➔What is going to happen to this patient after discharge?

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1

Outpatient: The 1st Year

➔ Key = Medical Group

➔ Set up as an Office Practice

➔ Shared space for 1st year

➔ Patients by MD referral

➔ MD – RN Model

7

Facilities Other

Offices

Home Hospice

Office

Practice

Hospitals

Select the

Venue

2

Outpatient Parameters

➔ Referral process

➔ Electronic Health Record

Templates

➔ ESAS

➔ Advance Care Planning

➔ Discharge Folders

– Brochure

– Opioid Safety

– After Visit Summary

8

Scheduling Standardization

➔ All appointments are 60

minutes

➔ 6-8 patients/day

➔ NN in room with MD for

all New and most Follow

Up visits

➔ Weekly interdisciplinary

team rounds (2+ hours)

➔ Visits outside of office day

9

Outpatient Referral Form

10

Outpatient Referral Form

ESAS and

Advance Care Planning

11

Outpatient Parameters

• Full day at 2 sites

• Following ~ 80 patients

• ~ 20 referrals/month

• 3 New Appointments/Office

Day

• Visits “without walls” at

other locations:

– Oncology Office

– Infusion Center

– Skilled Nursing

Facility/Nursing Home

– Home +/- Hospice 12

FY12 FY13 FY14 FY15

Days 1 2 2-3 3-4

MD 0.2 0.4 0.6 1.0

NP 0 0 0 1

RN 1 2 3 3

LPN 0.4 1 1 2

Staffing Estimates

Visits “Without Walls”: How?

➔ “Without Walls” based on:

– Urgency of clinical need

– Patient functional status

(Can they get to other

appointments?)

– Patient convenience

(Oncology/Infusion Center)

• Concurrent Scheduling

➔ Most Difficult

– Chronic non-urgent visits

➔ MD/NP “Flex” Scheduling

– 8-12 non-inpatient

weeks/year per provider

– Non-inpatient weeks cover

“without walls” need

➔ Administrative Time

– 0.5 of Medical Director

➔ Full-Time Nurse

Practitioner and Nurse

Navigators

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Staff Schedule

The Nurse Navigator

➔ Ambulatory Clinical

Resource for Advanced

Medical Home

➔ >65 Nurse Navigators

(Embedded and Virtual)

➔ Intense training process

including specific electronic

health record

documentation

➔ 3 full time Palliative Nurse

Navigators

– Medical Home budget

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The Palliative

Nurse Navigator

➔ Specifically selected and interviewed

➔ Specific competencies developed

➔ Communication skills emphasized

➔ Integrated into office visit model

➔ Trained in Advance Care Planning

➔ Assess and address needs in “without

walls” visits

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Our Space

The Challenges

Identity Crisis Sent: Monday, October 06, 2014 10:24 AM

To: BSR-Palliative Outpatient

Subject: phone call

Caller: Mrs. H

Patient: Mr. H

DOB: XX-XX-XXXX

Reason for call: wants to know if we will

come to house to give him flu shot and

pneumonia shot or does she need to take

him to drugstore.

Call directed to: Hope

Call back number: XXX-XX-XXXX

Best call back time: when you can pls

Level of urgency:

Patient told to bring to drug store and

response:

“Done….she sounded a little

disappointed. She said “ I thought this was

the sort of thing palliative would take care of”

➔ Palliative Medicine flyer in

new patient folder to

describe services

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Things We Tried that Didn’t Work

➔ MD Referral Model

➔ Shared/Rotated outpatient

responsibilities with all

MDs/NPs

➔ MD seeing patients

wherever they are / at any

time

➔ Following patients in

Hospice that we don’t

know well

Agreeing to see patients for the

wrong reasons…

Electronic Health Record Referral

Statements

➔ “Referral received. Patient will

receive phone call from Palliative

Medicine within 24 hours to

schedule first available

appointment."

➔ "Referral received. Patient not

scheduled. Practice notified of

other resources to support patient

needs."

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Case Example

➔ 58 year old with end stage COPD, multiple admissions

over the past year

➔ Consulted inpatient while in ICU, began to work with

patient and family on understanding illness and

prognosis

➔ Over several weeks post-discharge, symptoms and

needs escalated (calls, office & home visits with

different staff members)

➔ Escalated to emergency, MD visit to home and patient

died that night without Hospice

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Recognizing the Need

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Lesson Learned

What is “failure”?

➔Any ED visit, Admission, or Death

BEFORE 1st Touch after referral

Prioritize urgent needs

➔All referrals reviewed by LPN

➔Urgent referrals receive immediate

call by RN

➔Recognizing escalating need (see

graph)

Lesson

➔Too much chronicity depletes the

ability to respond to urgent need

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0

0

Pat

ien

t N

ee

d

Time

Graph of Patient Need

Outpatient Data Set

Measure Result

Mean age 62.5 years

Female 172/284 (61%)

Mean Initial Palliative

Performance Scale

63

Cancer* 179/273 (66%)

Advance Directives* 193/269 (72%)

Do Not Resuscitate 146/264 (55%)

Deaths 145/259 (56%)

Hospice Referral* all: 112/284 (39%)

died: 104/145 (72%)

Hospice Length of

Stay

median 21.5 days

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Data Set:

➔ Start to June 30, 2014

➔ 284 unique patients

Measuring:

➔ Demographics

➔ Descriptors

➔ Quality measures

➔ ESAS

➔ Outcomes

➔ ACP

➔ Hospice LOS

Outpatient Visits by Year

Unique Patients

# Encounters

FY12 – 2nd 59 166

FY13 – 1st 76 206

FY13 – 2nd 72 200

FY14 – 1st 77 192

FY14 – 2nd 110 295

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1059 OP Visits February 2012 to June 30, 2014

Note: Data derived from billing, all outpatient, non-hospice codes

Length of Follow up

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Days between initial

and most recent visit

N

➔ Most patients we follow for

<30 days (160)

➔ Fewer patients we follow

longer (~90)

➔ 30 days to 6 months (60)

➔ 6 months to 1 year (~30)

➔ Even fewer we follow for >12

months (~20)

Low and High Frequency Patients

➔ 1 or 2 visits

➔ More patients (169)

➔ Higher % deaths (61%)

➔ Slightly older (64yrs)

➔ Higher % cancer (69%)

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High Frequency

Patients

Low Frequency

Patients

➔ 5 or more visits

➔ Fewer patients (64)

➔ Lower % deaths (43%)

➔ Slightly younger (60yrs)

➔ Lower % cancer (53%)

# Visits/Patient and Hospice LOS

28

21 23

29

33 33

39

44

41 41

0

5

10

15

20

25

30

35

40

45

50

0 1 2 3 4 5 6 7 8 9 10

Ho

spic

e M

ed

ian

LO

S (d

ays)

Minimum number of clinic visits (at least N visits)

Basic Financials

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1/1/12-

8/31/12

9/1/12-

8/31/13

9/1/13-

6/30/14

Billed 69,217 154,725 156,765

Reimbursed 23,888

(33%)

53,699

(35%)

46,668

(30%)

Number of

Visits

173 406 398

Outcomes

➔ Most patients have or complete an Advance

Directive with us

➔ Most patients are dying with support of Hospice

– High percentage are referred to our health

system’s Hospice program

➔ Among all patients who die, their median LOS in

Hospice is longer than the national average

➔ The more visits we with have with a patient, the

longer their Hospice LOS

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Next Steps

➔ Full-Time LCSW for outpatient services

➔ Integrated “Palliative Home Model”

– Similar to “AIM” or “Bridge” programs

– Previously in Home Health

• Home Health limitations to provide service to patients not homebound

or without skilled need

– Hospice model (RN / LCSW) with provider support (MD / NP)

– Developing triggers for referral based on “compassionate care”

population

➔ Honoring Choices Virginia ACP Pilot

– Richmond Community / Respecting Choices Model

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Summary and Conclusions

➔ With resource support, Palliative

Medicine can provide care “without

walls”

➔ The empowered Nurse Navigator is

an essential ambulatory resource for

the seriously ill

➔ We have learned many lessons,

with the most critical being “the

graph of patient need”

➔ Bon Secours Virginia will share

resources and lessons learned

throughout their palliative care

journey

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Questions and Comments

➔ Do you have questions for the presenter?

➔ Click the hand-raise icon on your control panel to ask

a question out loud, or type your question into the chat

box.

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Leanne Yanni, MD

Medical Director, Palliative Medicine Bon Secours Virginia Health System

Leanne_Yanni@bshsi.org