Integrating Palliative Care into a Health System: A Continuing Conversation (Part 2)

Dec 08, 2014

This next installment of the Continuing Conversation series from the 2014 Palliative Care Symposium, focuses on questions that were posed throughout the Symposium regarding the complexity of systems integration. Responses have been provided by Charles F. von Gunten, MD, PhD, who is the Vice President of Medical Affairs, Hospice, and Palliative Care at OhioHealth Kobacker House. Dr. von Gunten is known for developing an early model of hospital-based palliative care that is reportedly used in 60% of palliative care programs nationwide. He also is the Editor-in-Chief of the Journal of Palliative Medicine.

The Symposium was co-sponsored by the American Society of Clinical Oncology (ASCO), the American Academy of Hospice and Palliative Medicine (AAHPM), the American Society for Radiation Oncology (ASTRO), and the Multinational Association of Supportive Care in Cancer (MASCC). Next year’s Symposium will be held October 9-10 in Boston.

Q: Please provide practical guidelines regarding how practicing providers can best integrate supportive care teams into practice.

Dr. von Gunten: In general, supportive care teams are supported by general oncology revenues—not by fee-for-service billing alone. Although physicians, nurse practitioners, social workers, and even chaplains who bill “incident-to” a psychiatrist can bill for services, the full cost is born by the oncology practice as a whole. In addition to improved patient care, improved oncologist and other professionals’ efficiency and improved work-life of everyone in the office are justifications. In addition, in risk-sharing environments, prevention of admissions is another benefit of supportive care teams in the outpatient setting.

Because of the payer mix and because details of oncology practice vary so much, more practical guidelines are impossible.


Q: In my practice of palliative care, I identified as a problem the circulation of the information about individual patients and the integration of that information into the daily practice of each member of the entire team. One of my propositions for a solution for this is an "interdisciplinary discussion about hospitalized patients” once a week. This practice is difficult to integrate. Do you have opinions about this? Do you have recommendations?


Dr. von Gunten: Many offices get together once a week to discuss challenging patients. In some, this is a brief huddle, and in others, they sit down for longer. The main issue is attributed value. An hour together is an hour not spent in billable activity. In most settings, there is the sense that the productivity during the rest of the week is improved, as is the morale of the office staff. Therefore, getting agreement from the participants about value is important. 

Q: What is your current process for maintaining continuity of care for patients who transition through the system?

Dr. von Gunten: A unified electronic medical record is regarded by many as a key feature. A second is serendipitous interaction that comes from the outpatient setting in close proximity to the inpatient setting, where staff can easily go between and/or encounter people from both inpatient and outpatient settings. I don’t know of any offices that are at distance from the hospital that feel like they have good continuity without real people going between the two settings.

Q: If palliative care and supportive care are different teams, how do you manage the shift of team when the patient evolves from supportive care to palliative care?

Dr. von Gunten: Joint visits and “warm” handoffs can help. If the two teams demonstrate in the presence of the patient that they work together and collaborate well, it’s rarely an issue.

Note: Please see:
--Part 1 of the Continuing Conversation series from the 2014 Palliative Care Symposium, "Q&As from the Palliative Care in Oncology Symposium: A Continuing Conversation," with responses by Timothy J. Moynihan, MD, Inpatient Practice Chair for the Department of Medical Oncology, Director of the Brain Tumor Clinic, and the Hospice Medical Director at the Mayo Clinic, Rochester.

—Part 3 of the Continuing Conversation series: “Advance Directives and Advance Care Planning: A Continuing Conversation (Part 3)” featuring responses by Joanna Paladino, MD, who presented on this topic at the Symposium and who is a research fellow for the Serious Illness Care Program at Ariadne Labs, which is a joint Innovation Center of the Harvard School of Public Health and Brigham and Women’s Hospital. Additional authors, all also from the Serious Illness Care Program at Ariadne Labs, included: Rachelle Bernacki, MD, MS, associate director; Francine Maloney, MPH, project manager; and Susan Block, MD, director.

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