Training the Workforce: Description of a Longitudinal Interdisciplinary Education and Mentoring Program in Palliative Care

Accepted Manuscript Training the Workforce: Description of a Longitudinal Interdisciplinary Education and Mentoring Program in Palliative Care Stacie Levine, MD, Sean O’Mahony, MB, BCh, BAO, MS, Aliza Baron, MA, Aziz Ansari, DO, Catherine Deamant, MD, Joel Frader, MD, Ileana Leyva, MD, Michael Marschke, MD, Michael Preodor, MD PII:

S0885-3924(16)31219-2

DOI:

10.1016/j.jpainsymman.2016.11.009

Reference:

JPS 9334

To appear in:

Journal of Pain and Symptom Management

Received Date: 15 April 2016 Revised Date:

25 July 2016

Accepted Date: 2 November 2016

Please cite this article as: Levine S, O’Mahony S, Baron A, Ansari A, Deamant C, Frader J, Leyva I, Marschke M, Preodor M, Training the Workforce: Description of a Longitudinal Interdisciplinary Education and Mentoring Program in Palliative Care, Journal of Pain and Symptom Management (2017), doi: 10.1016/j.jpainsymman.2016.11.009. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Brief Report

16-00237R174

Program in Palliative Care

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Stacie Levine MD University of Chicago 5841 South Maryland Ave MC 6098 Chicago, IL 60637 Phone (773) 834-8130 Fax (773) 702-3538 [email protected]

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Training the Workforce: Description of a Longitudinal Interdisciplinary Education and Mentoring

Sean O’Mahony MB, BCh, BAO, MS, Rush University Medical Center, Chicago, IL Aliza Baron MA, University of Chicago, Chicago, IL Aziz Ansari DO, Loyola University, Maywood, IL

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Catherine Deamant MD, JourneyCare, Barrington, IL

Joel Frader MD, Lurie Children’s Hospital, Northwestern University, Chicago, IL Ileana Leyva MD, Northwestern Medicine Central DuPage Hospital, Winfield, IL Michael Marschke MD, NorthShore University HealthSystem, Evanston, IL

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Michael Preodor MD, Advocate Medical Group, Park Ridge, IL

Tables: 5 References: 25 Word Count: 3,095

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ABSTRACT Context. The rapid increase in demand for palliative care (PC) services has led to concerns

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regarding workforce shortages and threats to the resiliency of PC teams. Objectives. To describe the development, implementation, and evaluation of a regional interdisciplinary training program in PC.

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Methods. Thirty nurse and physician “fellows” representing 22 health systems across the

Chicago region participated in a two-year PC training program. The curriculum was delivered

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through multiple conferences, self-directed e-learning, and individualized mentoring by expert local faculty (“mentors”). Fellows shadowed mentors’ clinical practices and received guidance on designing, implementing and evaluating a practice improvement project (PIP) to address gaps in PC at their institutions.

Results. Enduring, interdisciplinary relationships were built at all levels across health care

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organizations. Fellows made significant increases in knowledge and self-reported confidence in adult and pediatric PC and program development skills, and frequency performing these skills. Fellows and mentors reported high satisfaction with the educational program.

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Conclusion. This interdisciplinary PC training model addressed local workforce issues by increasing the number of clinicians capable of providing palliative care. Unique features include

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individualized longitudinal mentoring, interdisciplinary education, on-site project implementation, and local network-building. Future research will address the impact of the addition of social work and chaplain trainees to the program.

Accepted for publication: November 2, 2016

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INTRODUCTION The increase in demand for PC services, with the coinciding acute shortage of hospice and palliative medicine (HPM) physicians, [1] has led to concerns about clinician burnout and threats

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to long-term sustainability of programs [2]. Given this, emphasis is being made to increase training in basic PC skills for primary care, subspecialty, and other interdisciplinary clinicians

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[3,4]. Many existing programs offer valuable educational opportunities, some with the addition of brief mentoring support [5,6,7]. Mentoring in medicine is an established means of professional development, primarily in the academic setting where success is linked to faculty development, research productivity, well-being, and job satisfaction [8-13]. Yet, little is known about the value of mentoring in PC education and program development, particularly in

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community-based settings. In 2011 the Chicago Regional Palliative Medicine Physicians’ Collective was formed to identify local gaps in PC services and establish a collaborative network amongst interdisciplinary providers. It is comprised of local experts representing non-profit

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hospices, academic medical centers, a safety net hospital, and community-based hospitals. With support from a local non-profit organization, the Collective established the

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Coleman Palliative Medicine Training Program (CPMTP).

The CPMTP is a 2-year training program for physicians and nurses at Chicago area health systems seeking to increase access to PC services. Program goals are to 1) identify and address gaps to high quality care; 2) train interdisciplinary clinicians in primary PC; 3) provide structured longitudinal mentorship to new and developing programs; and 4) build an enduring supportive regional network of PC clinicians. This paper describes the development, implementation, and evaluation of the CPMTP from 2013-2015. Further evaluation of the

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program impact on patient outcomes and growth of PC teams is on-going and will be published separately. METHODS

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Recruitment

Initial recruitment targeted Chicago area hospitals that reported health outcomes data below the fiftieth percentile on key end-of-life indicators available on the Dartmouth Atlas of Healthcare

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[14] and those serving economically disadvantaged populations. Eighteen out of 29 hospitals met these criteria. The search was expanded to include other institutions within 30 miles of

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Chicago. Five core faculty and program directors contacted 50 sites including communitybased hospitals, veterans administration hospitals, long term acute care hospitals, and academic medical centers. They spoke directly with hospital administrators to discuss the institution’s interest in developing or growing PC services. Leadership was encouraged to

lasting change.

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identify adult and pediatric nurse and physician champions with the skills and abilities to affect

Selection of Coleman Fellows

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Applicants submitted a narrative describing their experience and interest in PC, role as an educator or leader in their health system, a proposed practice improvement project (PIP) and a

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rationale for its need. A letter of support from hospital leadership was also required that stipulated protected time and resources for program activities. Applicants participated in a structured telephone interview with a core faculty member, and were evaluated based on their professional profiles (current position, level of motivation), institutional need, leadership commitment, and potential impact of the PIP. Prior PC experience was not required. Selection and Role of Faculty Mentors

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The Collective invited 16 board certified HPM physicians and 6 advanced practice nurses to participate as faculty mentors. Mentors were seasoned clinicians and educators in pediatric and adult PC. Over half were directors of hospital-based clinical programs, HPM fellowships, or

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local hospices. Practice sites included community hospitals, academic medical centers, a safety net hospital, and home-based care. Mentors were paired with one to three fellows with consideration for practice setting, proximity and discipline. Mentor responsibilities were outlined

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in a Mentor Agreement and included at least monthly contact with fellows, guiding PIPs and direct observation of his/her clinical practice, attending and teaching at program conferences,

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and quarterly phone conferences with the project directors for support and discussion of fellows’ progress and needs. Mentor-mentee pairs created an individualized mentoring plan which targeted knowledge gaps self-identified by the fellow and pre-surveys. In addition, project specific skills were addressed, such as identifying and trouble-shooting barriers to PIP implementation, tracking metrics, and execution of educational interventions. Several mentors

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presented at continuing medical education conferences and/or met with hospital leadership at fellows’ sites to support system-based practice change. Fellows and mentors received stipends for their effort. This project was approved by Institutional Review Boards at the University of

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Chicago and Rush University Medical Center.

CPMTP Course Design, Structure and Content

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The CPMTP curriculum is designed to be incorporated into a full-time employee schedule and comprised of four main components: 1) live conferences; 2) self-directed online learning; 3) direct observation of the mentor’s clinical practice; and 4) development, implementation, and evaluation of a PIP. It centers on 29 essential adult and pediatric PC clinical and program development skills which were identified through an iterative process by the Collective.

The conferences were designed specifically to build knowledge and skills in critical areas of PC, prepare fellows to design PIPs, and foster relationships among fellows and mentors across 5

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institutions. A 2-day intensive on foundational topics initiated the CPMTP, followed by two 1day conferences occurring at six months and one year, respectively. An optional Mindfulness Based Stress Reduction Workshop series was added at no-cost at 18 months. A poster

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presentation and awards ceremony culminated the training program (Table 1). Continuing education credits were made available.

Fellows completed 20 hours of self-directed learning on an open access e-library on the

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program website (www.colemanpalliative.uchicago.edu). It is a compilation of free and feebased educational modules developed by PC experts from academic medical centers and

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interdisciplinary professional organizations. Each module was reviewed and selected by core faculty based on suitability for novice and intermediate-level PC learners. Additional resources on PC program development, quality improvement tools, and teaching materials are available on the program website. Fellows selected modules to address their perceived knowledge gaps,

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and reported their completed work to the project coordinator.

Practice Improvement Projects

PIPs were a critical component to the training, standing for real change in processes and quality

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of PC services to patients and families. These projects challenged fellows to identify unmet PC needs at their health care institutions, develop and implement appropriate interventions, enlist

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the buy-in of leadership and other key stakeholders, and evaluate the impact on individuals and systems. Fellows were encouraged to develop projects that were meaningful, aligned with institutional priorities, and feasible within the 2-year training program. The PIPs were intended to have measurable outcomes and a plan for sustainability. Project goals, action plans, evaluation methods, and a timeline were mapped out using an “Intent to Change Contract” (ICC) tool. (available at http://colemanpalliative.uchicago.edu/practice-change-projects/). The ICCs were used by the fellows and mentors to journal progress, identify and create solutions to

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barriers, and maintain the project timeline. Project outcomes were presented during a poster session and awards ceremony at the close of the 2-year training period. Examples of PIPs are available in Table 2. More complete descriptions of PIPs will be published separately.

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Leadership Engagement

The project directors, core faculty, and mentors devoted substantial time educating stakeholders on the value of PC. This occurred via teleconferences, face-to-face visits, on-site CME lectures,

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and progress report letters. Outreach to institutional leaders was continuous. At 6 months, leadership was invited to attend the 2013 fall conference business planning sessions. At one

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year, individualized PIP progress reports were sent to hospital administrators. A one-day regional leadership summit was held, featuring a national guest speaker and addressing national trends in PC, challenges and opportunities locally, business planning essentials, and private payer perspective on PC. Eighty hospital administrators and PC leaders attended.

ceremony. Evaluation

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Hospital leadership and administrators also attended the poster presentation and awards

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Fellows’ knowledge was assessed pre-training and at 18 months using End-of-Life Physician Education Resource Center (EPERC) #2, a commonly used, 40-item multiple choice test

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developed at the Medical College of Wisconsin. Fellows also completed a non-validated pre/post survey developed by core faculty through an iterative process which assessed confidence and frequency performing 24 core skills in adult PC and program development. An optional 5 questions in pediatric PC were also included. A 5-point Likert scale measured confidence from “very high” to “very low” and frequency from “always” to “never.” Study data were collected and managed using REDCap electronic data capture tools hosted at University of Chicago. REDCap (Research Electronic Data Capture) is a secure, web-based application

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designed to support data capture for research studies by providing an interface for validated data entry, audit trails for tracking data, and procedures for importing data from external sources [15]. Fellows provided feedback and evaluation of individual conference teaching sessions,

planning and provided feedback to presenters.

Analysis

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including 1-2 new skills learned per session. These findings informed future conference

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Pre and post-CPMTP scores on the knowledge test and skills’ assessment survey results were analyzed with paired sample t-tests on SPSS version 22 (SPSS, Chicago, IL). In the skills’

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analysis, results were adjusted using the Bonferroni correction. Overall satisfaction with conference sessions was calculated by aggregating evaluations for all modules over the 2 year training period. RESULTS

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Impact on Growing the Workforce

Fifty-two applicants were interviewed, resulting in 35 Fellows accepted into the program. The majority were female (87%), from adult programs (90%), and practiced in inpatient settings

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(77%). Slightly over half (57%) were employed in community-based health systems. They comprised a diverse learner group in different stages of professional development and from

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various disciplines. Two-thirds of the Fellows were dedicated PC providers. The remaining one-third were professionals who intended to incorporate PC skills into their practices and train their colleagues to do the same. Examples include a trauma surgeon at a safety net hospital who implemented a mindfulness based stress reduction program for her team and a communitybased advanced practice nurse who incorporated advance care planning into her nephrology practice. More than one third were self-reported novices (less than one year in PC practice); 43% were intermediate (1-5 years); and 20% were considered advanced (> 5 years) (Table 3).

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Thirty fellows (86%) completed the CPMTP. Five withdrew following employment changes or for personal reasons. Four fellows changed employers and pursued a PIP at their new site.

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Impact on Knowledge and Self-Assessment of Skills The CPMTP had an overall favorable impact on the fellows’ knowledge with average scores of 31.16 improving to 34.26 (S.D. 0.675, p<0.001) at 20 months. Fellows’ confidence increased significantly in 17 of 18 adult PC skills and in all 6 program development (PD) skills, and in 3 of

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5 pediatric PC skills. Frequency performing adult PC skills increased significantly in 15 of 18 skills; in 5 of 6 PD skills; and in 1 of 5 pediatric PC skills. Aggregate analyses of respective

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adult and pediatric PC skills and PD skills resulted in significant change (Table 4). Impact on Satisfaction of Conferences, Mentoring, and Program Design Fellows rated the conference sessions highly regarding appropriateness of content and integration of the materials into their clinical practice (composite mean scores ranging 4.62 to

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4.74 out of 5). Qualitative feedback yielded positive comments and suggestions for future program improvements. Namely, the fellows and mentors felt the CPMTP provided meaningful and rewarding collaboration and networking opportunities with means for professional and

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personal development. They appreciated the shadowing experience and ability to interact with experienced clinicians at another institution, yet suggested that shadowing opportunities with

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multiple mentors are offered to learn a variety of best practices and approaches to care. Mentors requested that mentorship education or a toolkit be made available at the outset, and if possible, to observe fellows in their clinical roles at their host institutions. Time management and institutional barriers were confounders that impacted some of the participants. Qualitative comments are provided in Table 5.

DISCUSSION

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The CPMTP yielded positive results in Fellows’ knowledge, confidence, and frequency practicing essential PC skills. The program duration of two years provided sufficient time for most fellows with full-time positions to successfully complete program requirements and

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implement a PIP, particularly where there was intersection between work responsibilities and project goals. All mentors remained committed for the program duration. Qualitative comments from fellows revealed high satisfaction regarding networking and mentorship and many lessons

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learned for future iterations of the program. A local, interdisciplinary network of PC providers formed among fellows and mentors within and across institutions. The CPMTP design is a

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unique combination of direct observation of seasoned clinicians’ practice, interactive conference sessions tailored to trainees’ educational needs including resilience-building, one-on-one guidance around PIPs, and self-directed learning, resulting in regional interdisciplinary network building.

The predominant limitations to this model are the time requirement of all parties and the

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necessary financial support. In addition, a comprehensive program evaluation was not conducted to ascertain which program components were most impactful. However, early feedback from program participants was extremely positive, leading to support from the funder

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for a second cycle which added eight new health systems and 29 new interdisciplinary fellows. Data collection on the impact of mentorship and PIPs over time is on-going.

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The following should be considered when creating a similar wide-ranging educational program: 1) Future work should evaluate the use of structured mentoring programs to assist with local PC team-building and sustainability. Effective mentoring is considered to be a fundamental component necessary for success in medicine, yet there is limited published data on the role of mentoring outside of academic environments [16-20], particularly in regards to PC. One model, CHIPS (California Hospital Initiative in Palliative Services), sought to increase the number of statewide inpatient PC programs by training teams from 38 hospitals [21]. The training involved

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two conferences and mentoring from an assigned faculty mentor, including scheduled conference calls, emails, and on-site consultation over 10 months. The results were positive, with 60% of hospitals establishing a PC program after participation in CHIPS. Participant

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evaluation noted personal contact with faculty and teams from other hospitals as being most beneficial. Similarly, the relationships that were built through the CPMTP (peer-peer, mentormentee, and mentor-mentor) were consistently regarded as the most impactful aspect of the

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program. They provided innumerable benefits that included sharing educational resources, process improvement methods, and strategies to overcome institutional and project-specific

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barriers to PC program growth.

Given the needs for engaging the workforce to promote resiliency of clinicians and teams it is imperative that we look at ways to strengthen relationships across disciplines. The Palliative Care and Hospice Education and Training Act (PCHETA) which intends to fund Palliative Care and Hospice Education Centers to improve the training of physicians, nurses, and other allied

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health professionals in PC is a vital program necessary to address workforce development and retention of the field [22]. The CPMTP begins to address many of PCHETA goals. We have extended our program to include social worker and chaplain fellows and mentors into the

2)

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second phase of the program (2015-2017), which emphasizes transdisciplinary learning. Institutional commitment goes beyond a letter of support. Even the most well-intentioned

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hospital administrator may not have a firm understanding of the investment in resources needed to support a PC team or to complete a PIP. Multiple efforts were made by core faculty and mentors to engage leadership throughout the duration of the program that included progress reports, site visits, and a one-day PC Leadership Summit that was widely attended by institutional leadership. The conference featured presentations from local hospitals that had successfully implemented programs as well as a national leader in program development for PC services.

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3)

Pediatrics faces unique challenges. Despite being in a large metropolitan area, the small

number of established pediatric PC programs limited the availability of local mentors. Lack of institutional support for dedicated pediatric PC time created difficulties towards successful

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completion of PIP project goals for some participants. Nevertheless, the CPMTP helped build relationships across institutions so pediatrics fellows felt less isolated and better supported by others in the region who encountered similar institutional barriers.

Healthcare climates are constantly in flux. With Accountable Care [23] the health care

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4)

environment in the Chicago region has undergone significant change over the past five years.

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There were several instances of hospital mergers resulting in leadership turnover during the training program. Often these leaders were the original service line administrators for the fellows, which threatened the loss of fiscal support for their programs. Safety-net and urban community hospitals struggled more than institutions with more robust, financially-sound programs. There was also evidence of job turnover with 5 of 29 Fellows and 4 of 22 Mentors

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changing positions midway through the program. Whether this is an expected pattern in health care versus a marker of employee burnout in PC is currently unknown. However, this was less than the average turnover rate of 19.2% reported to healthcare employers in 2015 [24]. Some

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of the fellows encountered unanticipated hurdles that delayed and, in some cases, prevented implementation of their original PIPs. Through the supportive network that was created, the

5)

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fellows were advised on how to redesign projects and effectively engage new leadership. In this field we need to take care of each other. Many of the fellows reported feeling

stressed by the institutional expectation of providing full-time patient care while performing skills outside of their original scope of practice. This included the expectation to educate other clinicians, devise clinical benchmarks, collect data, report to leadership, and support other team members. Many of our fellows were working solo, particularly in community-based hospitals, which compounded these challenges. These individuals were especially vulnerable to burnout

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and compassion fatigue and required more intensive support from the mentors and core faculty. Because of this concern there was an increased emphasis on self-care and addition of mindfulness training offered in the CPMTP programming [25].

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6) Cross-organizational collaboration is central to building a wide-ranging educational program. Cross-organizational collaboration made curriculum development and delivery more feasible throughout the program. The core work group identified a diverse array of faculty with expertise

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who facilitated customization of content, thus ensuring that the curriculum was relevant to different institutional settings, clinical practice types, and multiple learner levels. This

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collaborative model was also pivotal in obtaining substantial resources from a local funder because of the higher likelihood of scalability and impact on workforce development in the region. CONCLUSION

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The CPMTP is a successful model for growing a local trained workforce in PC, which focuses on the development of building knowledge and skills, intensive longitudinal mentorship, and team resilience. Future work will assess the impact of incorporating social worker and chaplain

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learners and mentors into this palliative medicine educational program. DISCLOSURES AND ACKNOWLEDGEMENTS

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This project was funded by the Coleman Foundation (www.colemanfoundation.org) but was designed, implemented and evaluated independently from the Foundation. No authors have financial or other conflicts to report. The authors enthusiastically thank the mentors and fellows for their dedication to this program. BIBLIOGRAPHY

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2. Kamal AH, Bull JH, Wolf SP, et al. Prevalence and predictors of burnout among hospice and palliative care clinicians in the U.S. J Pain Symptom Manage 2015. [Epub ahead of print]. Accessed March 18, 2016.

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3. Frist WH and Presley MK. Training the next generation of doctors in palliative care is the key to the new era of value-based care. Acad Med 2015;90(3):268-271.

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4. Quill TE and Abernathy AP. Generalist plus specialist palliative care – creating a more sustainable model. N Engl J Med. 2013;368(13):1173-1175.

5. Hauser JM, Preodor M, Roman E, Jarvis DM, and Emanuel L. The evolution and dissemination of the Education in Palliative and End-of-life Care (EPEC) Program. J Palliat Med 2015;18(9):765-70.

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6. End-of-Life Nursing Education Consortium (ELNEC). History, statewide effort, and recommendations for the future. Available from: http://aacn.nche.edu. Accessed April 8,2016.

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7. Center for Advancing Palliative Care. Palliative Care Leadership Centers. Available from: https://.capc.org. Accessed February 10, 2016.

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8. Sullivan AM, Lakoma MD, Billings JA, Peters AS, Block SD. Teaching and learning endof-life care: evaluation of a faculty development program in palliative care. Acad Med 2005;80(7):657-668.

9. Sambunjak D, Straus S, Marusic A. A systematic review of qualitative research on the meaning and characteristics of mentoring in academic medicine. J Gen Intern Med 2010;25(1):72-78. 10. Pololi LP and Knight S. Mentoring faculty in academic medicine: A new paradigm? J Gen Intern Med 2005;20(9):866-870. 14

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11. Jackson V, Palepu A, Szalacha L et al. “Having the right chemistry”: A qualitative study of mentoring in academic medicine. Acad Med 2003;78(3):328-334. 12. Steiner JF, Curtis P, Lanphear BP et al. Assessing the role of influential mentors in the

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research development of primary care fellows. Acad Med 2004;79(9):865-872. 13. DeCastro R, Griffith KA, Stewart A, Jagsi R. Mentoring and the career satisfaction of male and female academic medical faculty. Acad Med 2014;89(2):301-311.

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14. The Dartmouth Atlas of Health Care. Available from: http://www.dartmouthatlas.org. Accessed November 12, 2012.

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15. Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap): A metadata-driven methodology and workflow process for providing translational research informatics support, J Biomed Inform 2009;42(2):377-81.

16. Laukhaupt SE, Chin M, Mangione CM, et al. Mentorship in general academic medicine: results of a survey of mentors. J Gen Intern Med 2005;20:1014-1018.

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17. Tsen LC, Borus JF, Nadelson CC, et al. The development, implementation, and assessment of an innovative faculty mentoring leadership program. Acad Med 2012;87:1757-1761.

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18. Cho CC, Ramanan RA, Feldman MD. Defining the ideal qualities of mentorship: a qualitative analysis of the characteristics of outstanding mentors. Am J Med

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2011;124:453-458.

19. Aziz NM, Grady PPA, Curtis JR. Training and career development for palliative care and end-of-life research: opportunities for development in the United States. J Pain Symptom Manage 2013:46(6):1-12.

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21. Pantilat SZ, Rabow MW, Citko J, et al. Evaluating the California Hospital Initiative in Palliative Services. Arch Intern Med 2006;166:227-230. 22. Palliative Care and Hospice Education and Training Act. H.R. 3119 – 114th Congress.

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Available from: https://www.congress.gov. Accessed June 30, 2016. 23. Fisher ES, Shortell SM. Accountable care organizations: Accountable for what, to whom, and how. JAMA 2010;304(15):1715-1716.

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24. Compdata Surveys, Compensation Data Healthcare. Rising turnover rates in healthcare and how employers are recruiting to fill openings. Available at

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https://www.compdatesurveys.com. Accessed July 10, 2016.

25. O’Mahony S, Gerhart, JI, Grosse J, Abrams I, Levy MM. Posttraumatic stress symptoms in palliative care professionals seeking mindfulness training: Prevalence and

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vulnerability. Palliat Med 2016;30(2):189-192.

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Table 1: Educational Domains and Conference Sessions

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Foundations in Palliative Care • Gaps and Models of Care* • Whole Patient Assessment and Goals of Care* • Psychosocial Issues: Working with Families* • Spirituality* • Responding to Requests to Hasten Death* • Withholding, Withdrawing Life-Sustaining Treatments* • Last Hours of Living* • Pain Assessment and Management* • Delirium, Depression and Anxiety* • Narcotics Safety Pediatric Palliative Care • Key Issues in Pediatric Palliative Care for All Providers Pain Assessment and Treatment • Differentiating Pediatric Palliative Care from Adult Palliative and Hospice Care • Ethical Controversies in Pediatric Palliative and Hospice Care • Place of Death Determinations • Giving Bad News • Advanced Pain Management and Dosing Opioids Communication Skills • Communicating Difficult News* • Offering Value-Centered Recommendations • Conflict with Families Practice Improvement Project Skill Building • Introduction to Program Development • Introduction to Planning an Educational Event • Creating and Implementing a Business Plan in Palliative Care** • Creating and Implementing a Successful Palliative Care Educational Program Resiliency • Self-Care* • Tactics to Avoid Burn-out and Enhance Self-Care • Reflective Writing Exercise: On Being a Healer • Mindfulness Based Stress Reduction Workshop Series*** *Adapted from Education in Palliative and End-of-Life Care (EPEC) **Specialized breakout sessions for program development: intensive care units, safety net hospitals, outpatient settings, and pediatric care. ***Optional, 32 hours of training over 8 weeks (evenings and weekends)

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Table 2. Examples of Practice Improvement Projects Implemented by Interdisciplinary Fellows

Teaching Hospital

Increase Palliative Care Awareness through the Application of Goals of Care (GOC) Discussions and Educational Efforts

Pediatric Hospital

Raise Awareness and Increase Access to Pediatric Palliative Care

Community-based Hospital

Increase Palliative Care Consultations in the Emergency Department

INTERVENTIONS

OUTCOMES

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PROJECT TITLE


Utilized a screening tool to identify patients that would benefit from GOC.
Created a communication model to engage physicians and ensure GOC discussion held with patient.
Developed an educational curriculum to reach all hospital disciplines: physicians, nurses, chaplains, and case management teams.
Strengthened nursing home communication pathways, continuity and transitions in care.
Recruited an interdisciplinary comfort care team
Performed needs assessment for staff, physicians and families
Launched an inpatient consultation service, weekly educational comfort care rounds, monthly Reflective Reading sessions, yearly service of remembrance
Staff debriefings, as needed, for patient deaths/declining conditions
Assembled a task force of stakeholders
Completed a needs assessment of Emergency Department (ED) to assess knowledge of palliative care
Identified and recruited Emergency Department physician champion(s)
Developed and implemented screening tool and process for palliative care follow up
Collected metrics for referral and disposition

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SETTING


GOC discussions reported monthly via electronic medical record.
Readmission rates for patients with GOC discussion remained stable.
Communication pathways between nursing home partners and continuity of care have been strengthened.


Change in documentation of comfort care and palliative care consults
Educational program and the service of remembrance received excellent evaluations by all attendees.
Electronic medical record template modified/approved


Palliative care screening tool now actively used by the ED
ED physicians directly contact the palliative care service
Palliative care consults increased.
An additional nurse was hired to join the palliative care team.

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Table 3: Demographics of the Coleman Palliative Medicine Fellows N = 30

% of Fellows

Physician

10

33

APN

12

40

RN, PhD

2

7

RN

6

20

26

Male

87

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Female

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Sex

4

13

17

57

13

43

27

90

3

10

Inpatient

23

77

Outpatient

1

3

Home-based Care

3

10

Skilled Nursing Facility

3

10

<5

12

40

5-9

8

26

10 – 20

7

23

>20

3

10

Institution Type Community-based Academic/Teaching

Adults Pediatrics

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Patient Population Served

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Practice Setting

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Health Care Discipline

Years in Practice Setting

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25-34

7

23

35-44

5

17

45-54

13

43

55-64

5

17

Novice (< 1 year)

11

37

Intermediate (1 - 5 years)

13

43

Advanced (> 5years)

6

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Prior Experience in HPM (years)

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Age (years)

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ACCEPTED MANUSCRIPT Table 4. Fellows’ Self-Assessment of Palliative Medicine and Program Development Skills

Mean Ratinga

Assess pain and develop a differential diagnosis for its cause Manage pain using opioids

Manage pain using non-opioid and adjuvant

Confidence

3.23

Frequency

3.43

Confidence

2.93

Frequency

3.10

0.130

3.80

.928

0.039*

3.43

.861

0.003*

3.23

.937

0.442

2.90

3.73

.874

0.000*

2.80

3.23

1.165

0.057

Confidence

2.93

3.67

.740

0.000*

Frequency

2.50

3.00

1.042

0.014*

Confidence

2.90

3.43

.629 < 0.001*

Frequency

2.83

3.30

.937

Confidence

3.20

3.77

.626 < 0.001*

Frequency

3.00

3.33

.884

EP

Assess and treat dyspnea

Confidence

3.17

3.77

.675 < 0.001*

Frequency

2.77

3.27

1.106

Confidence

2.37

3.33

.765

Frequency

2.23

2.77

1.074

0.011*

Confidence

2.93

3.73

0.714

0.001*

Frequency

2.43

2.87

0.858

0.010*

Confidence

3.53

4.40

0.681 < 0.001*

Frequency

2.93

3.53

1.037

Confidence

3.50

4.50

0.643 < 0.001*

Frequency

2.97

3.83

0.973 < 0.001*

Confidence

3.53

4.37

0.834 < 0.001*

TE D

Assess and treat nausea/vomiting

AC C

Assess and treat delirium

Manage symptoms in actively dying patients

Provide support to family members of actively dying patients Participate in advance care planning with patients and families Discuss hospice care with patients and families

p-valuec

1.055

Confidence

Manage pain using non-pharmacologic measures

S.D.

3.53

Frequency

Assess and treat anxiety and depression

Post

M AN U

analgesics

Pre

RI PT

Measure (N = 30 for all skills in I and II)

SC

Skills I. Adult Patient Care

0.011*

0.048*

0.019* < 0.001*

0.004*

ACCEPTED MANUSCRIPT

Discuss prognosis with patients and families

Manage spiritual distress in patients

3.63

0.802 < 0.001*

Confidence

3.60

4.43

0.699 < 0.001*

Frequency

3.37

4.00

1.066

Confidence

3.40

4.13

.691 < 0.001*

Frequency

2.47

2.83

.890

Confidence

3.27

4.20

.691 < 0.001*

Frequency

2.90

3.30

1.076

Confidence

2.87

3.47

.770 < 0.001*

Frequency Confidence

Navigate common legal issues in palliative care

0.050*

2.80

.858 < 0.001*

2.80

3.63

.699 < 0.001*

Frequency

2.27

2.87

.855

Confidence

2.40

3.37

.718 < 0.001*

Frequency

1.90

2.23

.802

0.030*

Confidence

3.08

3.83

.363

0.000*

Frequency

2.72

3.21

.459

0.000*

Confidence

2.70

3.73

.809 < 0.001*

Frequency

1.90

2.63

.944 < 0.001*

Confidence

3.17

3.93

.774 < 0.001*

Frequency

2.47

3.20

1.311

Confidence

2.60

3.73

.776 < 0.001*

Frequency

1.63

2.43

1.031 < 0.001*

Confidence

2.70

3.37

.922 < 0.001*

Frequency

1.87

2.43

1.278

Confidence

2.77

3.50

.740 < 0.001*

Frequency

1.83

2.57

1.337

TE D

AGGREGATE: ADULT PALLIATIVE CARE SKILLS

0.032*

2.03

M AN U

Navigate common ethical issues in palliative care

0.003*

RI PT

Lead a discussion on communicating bad news

2.97

SC

Explain palliative care to patients and families

Frequency

0.001*

II. Program Development Skills

EP

Deliver teaching sessions in palliative care

AC C

Effectively lead an interdisciplinary team

Describe to stakeholders how palliative care can enhance the mission and financial bottom

0.005*

line of an organization

Leverage new and existing resources to build a palliative care program Conduct a needs assessment for palliative care

0.022*

0.005*

ACCEPTED MANUSCRIPT

AGGREGATE: PROGRAM DEVELOPMENT SKILLS

Confidence

2.66

3.33

.959

0.001*

Frequency

2.10

2.70

1.303

0.017*

Confidence

2.77

3.60

.622

0.000*

Frequency

1.97

2.66

.850

0.000*

III. Pediatric Patient Care

pediatric patients and their families Dose opioids for pediatric patients

2.22

(N = 4)

2.50

Frequency

(N = 9) Confidence (N = 10) Frequency

Assess pain in nonverbal pediatric patients Assess decisional ability of children at different ages Give bad news to children at different

AGGREGATE: PEDIATRIC SKILLS

a

3.22

.866

0.009*

3.75

.500

0.015*

3.22

.866

0.002*

1.50

2.00

.707

0.052

2.70

3.40

1.252

0.111

(N = 10) Frequency

2.20

2.20

.667

1.000

(N = 10) Confidence

2.30

3.10

1.033

0.037*

(N = 9) Frequency

1.67

1.78

.601

0.594

(N = 10) Confidence

2.20

3.00

1.229

0.070

(N = 8) Frequency

1.50

1.75

.707

0.351

Confidence

2.31

3.24

.943

0.018*

Frequency

2.10

2.95

.661

0.082

TE D

ages

(N = 10) Confidence

1.89

M AN U

under age 4

(N = 9) Confidence

SC

Provide palliative care services to

RI PT

Monitor performance improvement benchmarks

EP

A 5-point Likert scale was used to measure “Confidence in ability to perform skill” with 5=Very high

confidence, 3=Moderate, and 1=Very low; Anchors for measuring “Frequency performing skill” were

b

AC C

5=Always, 3=Often, and 1=Never.

This assessment was conducted at 18-months after the educational requirements were met.

c

P values are based on paired sample t-tests. Significance values have been adjusted for multiple variable

comparisons. *

Denotes statistically significant change

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Table 5. Qualitative Comments from Fellows and Mentors Education “Our educational experiences and relationships formed at the Coleman conferences benefited

RI PT

us and directly translated to improvements in patient care.” (Fellow)

“The discussions allowed us access to additional knowledge and experience of professionals from perspectives not our own. The role playing ...was especially valuable because it

SC

cemented that knowledge in a safe “practice” environment while also allowing us to experience directly the roles of team members. That understanding clarified how we support not only our

M AN U

patients and families, but our team members as well.” (Fellow)

“I think the learning environment for the Coleman conferences was unique and extraordinarily valuable. The wide range of learning experiences lecture, discussion, small group or role play served to support different learning styles and reinforce the material. The diversity of other learners also enhanced the experience.” (Fellow)

(Fellow)

TE D

“I like the two years [duration of the program] because I felt I needed a year to ramp up.”

Mentoring and Networking

EP

“I was one year into starting a palliative care program…it gave me a structured and scheduled

AC C

time to meet with mentors who gave me really good advice on what to do. And then also the shadowing was great.” (Fellow) “I think it would have been more valuable to follow the team a lot more, and see how they work...to actually have the experience of following people over a long period of time, I think would have been more valuable for myself.” (Fellow) “The relationships formed between the pediatric providers certainly created its own ‘coalition’ that has enhanced the collaboration in patient care.” (Fellow)

ACCEPTED MANUSCRIPT

“I was at another community hospital, so it was nice to see the parallel worlds and how a new program compares to an established program.” (Fellow) “It has been rewarding to witness and take part in a sharing of knowledge amongst institutions

RI PT

as well as the creation of such strong support networks. This has created a unique climate that allows for the fostering of ideas, comradery and growth of individuals in the pursuit for the advancement of palliative care.” (Mentor)

SC

“I have found the networking as a mentor for the Coleman program incredible. I have met and now collaborate with numerous providers. This has helped me not only professionally but also

M AN U

my patients to receive expedited palliative care in settings outside of mine.” (Mentor) “Mentoring providers in the Coleman fellowship has provided me great satisfaction. I have helped two programs initiate the delivery of palliative medicine to populations without access previously. The providers have affected the lives of countless people as a result of the

TE D

fellowship.” (Mentor) Practice Improvement Projects

“I felt my process improvement project, we were able to make improvements within our health

EP

system…So I think for the local culture, it was very important because then it had credibility of the process.” (Fellow)

AC C

“It demanded some buy-in from our institution. We actually tried to keep it really small but then we over-delivered on parts of it…the project actually changed our EMR…we got inpatient nurses involved…administrators need to know about it.” (Fellow) “My project was to do a pilot study on distress screening, and I think it turned out positive for our institution. Because not only we applied it to all patients, and we became compliant with CoC [Commission on Cancer] standards…I think my project was a trigger to do this massive distress screening in all patients.” (Fellow)