Practice Improvement Projects in an Interdisciplinary Palliative Care Training Program.

CONTEXT: Demand for palliative care (PC) continues to increase with an insufficient number of specialists to meet the need. This requires implementation of training curricula to expand the workforce of interdisciplinary clinicians who care for persons with serious illness. OBJECTIVES: To evaluate the impact of utilizing individual practice improvement projects (PIP) as part of a longitudinal PC curriculum, the Coleman Palliative Medicine Training Program (CPMTP-2). METHODS: Participants developed their PIPs based on their institutional needs and through a mentor, and participated in monthly meetings and bi-annual conferences, thereby allowing for continued process improvement and feedback. RESULTS: Thirty-seven interdisciplinary participants implemented 30 PIPs encompassing 7 themes: (1) staff education; (2) care quality and processes; (3) access to care; (4) documentation of care delivered; (5) new program development; (6) assessing gaps in care/patient needs; and (7) patient/family education. The majority of projects did achieve completion, with 16 of 30 projects reportedly being sustained several months after conclusion of the required training period. Qualitative feedback regarding mentors' expertise and availability was uniformly positive. CONCLUSION: The CPMTP-2 demonstrates the positive impact of PIPs in the development of skills for interdisciplinary learners as part of a longitudinal training program in primary PC. Participation in a PIP with administrative support may lead to operational improvement within PC teams.

Expanding the Interdisciplinary Palliative Medicine Workforce: A Longitudinal Education and Mentoring Program for Practicing Clinicians.

CONTEXT: The disparity between gaps in workforce and availability of palliative care (PC) services is an increasing issue in health care. To meet the demand, team-based PC requires additional educational training for all clinicians caring for persons with serious illness. OBJECTIVES: To describe the educational methodology and evaluation of an existing regional interdisciplinary PC training program that was expanded to include chaplain and social worker trainees. METHODS: From 2015 to 2017, 26 social workers, chaplains, physicians, nurses, and advanced practice providers representing 22 health systems completed a two-year training program. The curriculum comprises biannual interdisciplinary conferences, individualized mentoring and clinical shadowing, self-directed e-learning, and profession-focused seminar series for social workers and chaplains. Site-specific practice improvement projects were developed to address gaps in PC at participating sites. RESULTS: PC and program development skills were self-assessed before and after training. Among 12 skills common to all disciplines, trainees reported significant increases in confidence across all 12 skills and significant increases in frequency of performing 11 of 12 skills. Qualitative evaluation identified a myriad of program strengths and challenges regarding the educational format, mentoring, and networking across disciplines. CONCLUSION: Teaching PC and program development knowledge and skills to an interdisciplinary regional cohort of practicing clinicians yielded improvements in clinical skills, implementation of practice change projects, and a sense of belonging to a supportive professional network.

Racial and ethnic disparity in palliative care and hospice use.

OBJECTIVES: Prior research has demonstrated differences across race and ethnicity, as well as across geographic location, in palliative care and hospice use for patients near the end of life. However, there remains inconsistent evidence regarding whether these disparities are explained by hospital-level practice variation. The goals of this study were to evaluate whether inpatient palliative care consultation use and discharge to hospice differed by race/ethnicity and whether hospital-level variations explained these differences. STUDY DESIGN: Retrospective, cross-sectional study. METHODS: This study evaluated 5613 patients who were discharged to hospice or died during their hospital stay between 2012 and 2014 in 4 urban hospitals with an inpatient palliative care service. The main outcomes were receipt of an inpatient palliative care consultation and discharge to hospice. RESULTS: The sample was 43% white, 44% African American, and 13% Hispanic. After adjusting for patient characteristics and hospital site, race/ethnicity was not significantly associated with receipt of inpatient palliative care consultation. Hispanic race/ethnicity was associated with a higher likelihood of discharge to hospice (odds ratio, 1.22; P = .036), and inpatient palliative care consultation was associated with 4 times higher likelihood of discharge to hospice (P <.001). Hospital site was also associated with both receipt of inpatient palliative care consultation and discharge to hospice. CONCLUSIONS: Our results illustrate significant variation across hospitals in palliative care consultation use and discharge to hospice. No significant racial/ethnic disparities in the use of either palliative care or hospice at the end of life were found within hospitals.

Incorporating Older Adults as "Trained Patients" to Teach Advance Care Planning to Third-Year Medical Students.

BACKGROUND: Advance care planning (ACP) is a critical component of end-of-life (EoL) care, yet infrequently taught in medical training. OBJECTIVE: We designed a novel curriculum that affords third-year medical students (MS3s) the opportunity to practice EoL care discussions with a trained older adult in the patient's home. DESIGN: Volunteers were instructed as trained patients (TPs) to evaluate MS3s interviewing and communication skills. The MS3s received a didactic lecture and supplemental material about ACP. Pairs of MS3s conducted ACP interviews with TPs who gave verbal and written feedback to students. Student evaluations included reflective essays and pre/postsurveys in ACP skills. SETTINGS AND PARTICIPANTS: A total of 223 US MS3s participated in the curriculum. RESULTS: Qualitative analysis of reflective essays revealed 4 themes: (1) students' personal feelings, attitudes, and observations about conducting ACP interviews; (2) observations about the process of relationship building; (3) learning about and respecting patients' values and choices; and (4) the importance of practicing the ACP skills in medical school. Students' confidence in skills significantly improved in all 7 domains ( P < .001): (1) introduce subject of EoL; (2) define advance directives; (3) assess values, goals, and priorities; (4) discuss prior experience with death; (5) assess expectations about treatment and hospitalization; (6) explain cardiopulmonary resuscitation and outcomes; and (7) deal with own feelings about EoL and providers' limitations. CONCLUSIONS: The use of older adults as TPs in an ACP curriculum provides students an opportunity to practice skills and receive feedback in the nonmedical setting, thereby improving comfort and confidence in approaching these conversations for future patients.

Compassion Fatigue Among Palliative Care Clinicians: Findings on Personality Factors and Years of Service.

OBJECTIVES: Palliative medicine is a rewarding field, but providers encounter patient trauma on a routine basis. Compassion fatigue, marked by burnout, secondary traumatic stress, and low satisfaction may result. However, professionals differ markedly in how they respond to patient trauma. The objective of the current study was to determine whether personality traits of neuroticism and agreeableness relate to aspects of compassion fatigue, after accounting for time spent working in the field. METHODS: Sixty-six palliative medicine physicians, nurses, social workers, and chaplains completed validated measures of personality traits, compassion fatigue, and work background. RESULTS: Providers who had worked longer reported higher levels of satisfaction and lower levels of burnout. Neuroticism demonstrated strong significant associations with secondary traumatic stress and burnout ( Ps < .001). Agreeableness was significantly and strongly associated with compassion satisfaction ( P < .001). These associations held after accounting for years spent working in the field. SIGNIFICANCE OF RESULTS: Personality traits of neuroticism and agreeableness may convey risk and resilience, respectively, for palliative care professionals. More research is needed to determine if assessing personality traits can help identify providers at risk for adverse reactions to patient trauma.

Palliative Workforce Development and a Regional Training Program.

AIMS: Our primary aims were to assess growth in the local hospital based workforce, changes in the composition of the workforce and use of an interdisciplinary team, and sources of support for palliative medicine teams in hospitals participating in a regional palliative training program in Chicago. METHODS: PC program directors and administrators at 16 sites were sent an electronic survey on institutional and PC program characteristics such as: hospital type, number of beds, PC staffing composition, PC programs offered, start-up years, PC service utilization and sources of financial support for fiscal years 2012 and 2014. RESULTS: The median number of consultations reported for existing programs in 2012 was 345 (IQR 109 - 2168) compared with 840 (IQR 320 - 4268) in 2014. At the same time there were small increases in the overall team size from a median of 3.2 full time equivalent positions (FTE) in 2012 to 3.3 FTE in 2013, with a median increase of 0.4 (IQR 0-1.0). Discharge to hospice was more common than deaths in the acute care setting in hospitals with palliative medicine teams that included both social workers and advanced practice nurses ( p < .0001). CONCLUSIONS: Given the shortage of palliative medicine specialist providers more emphasis should be placed on training other clinicians to provide primary level palliative care while addressing the need to hire sufficient workforce to care for seriously ill patients.

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

CONTEXT: The rapid increase in demand for palliative care (PC) services has led to concerns 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. 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 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 to address gaps in PC at their institutions. RESULTS: Enduring, interdisciplinary relationships were built at all levels across health care 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. CONCLUSION: This interdisciplinary PC training model addressed local workforce issues by increasing the number of clinicians capable of providing PC. Unique features include 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.

The Curriculum for the Hospitalized Aging Medical Patient program: a collaborative faculty development program for hospitalists, general internists, and geriatricians.

BACKGROUND: The University of Chicago Curriculum for the Hospitalized Aging Medical Patient (CHAMP) faculty development program (FDP) is targeted at hospitalists and other internists who teach residents and students in the hospital setting. The aim of CHAMP is to increase the quantity and quality of teaching of geriatric medicine pertinent to the inpatient setting. METHODS: Hospitalist and general internist faculty members who attend on the University of Chicago Medicine teaching service were invited to participate. The CHAMP FDP consisted of twelve 4-hour sessions. Two hours of each session covered inpatient geriatrics content, and 2 hours addressed improving clinical teaching (both general teaching skills and challenges specific to the inpatient wards) and teaching the Accreditation Council for Graduate Medical Education core competencies with geriatrics content. The evaluation included a self-report survey of the impact on the graduates' teaching and clinical practice. RESULTS: The FDP was piloted in early 2004 with a core group of geriatrics and hospitalist faculty. Three subsequent cohorts totaling 29 hospitalist and general internal medicine faculty members completed the FDP by the fall of 2006. Faculty participants evaluated the program positively, and significant improvements in knowledge, attitudes to geriatrics, and perceived behavior in teaching and practicing geriatrics skills were found. CONCLUSIONS: The integration of teaching techniques and geriatrics content was enthusiastically accepted by University of Chicago hospitalists and general internists who teach residents and medical students in the inpatient setting. The program has potential for widespread suitability to all teaching faculty who care for the older hospitalized patient.

Ethics reporting in publications about research with Alzheimer's disease patients.

Persons with impaired decision-making capacity require special ethical protections during recruitment for and participation in research. To assess how fully basic protections for these persons were reported in the literature, the first structured review of a sample of reports of trials including Alzheimer's subjects was performed in 62 journals between January 1992 and December 1998. Neither institutional review board review nor informed consent was mentioned in 28% of the studies. In 48% of the studies, there was no mention of subject involvement in the consent process or that any potential subjects refused or withdrew. Protections may have been offered and simply not reported in the journal articles. The critical importance of these protections would be demonstrated if editors required that authors provide full documentation of ethical protections when submitting an article for review. These might be briefly reported in the articles but be made available electronically to interested readers. Authors could then specify in detail how they conducted their research involving persons with diminished decision-making capacity.

Improving medical care of persons with Alzheimer disease through clinical teaching: the IMPACT program.

The purpose of this project was to develop, implement, evaluate, and disseminate an educational program on ethics and the primary care of patients with dementia for residents. Pre/post-rotation self-confidence measure, a post-rotation assessment of the importance of and achievement of the program's goals, and a post-rotation evaluation of the program were administered. Significant increases in residents' confidence in performing the programmatic clinical goals and in overall confidence were found. Program goals were met, and components of the program were rated highly. We found that a well-designed ethics curriculum can be successfully implemented within a clinical rotation for medicine residents and have a positive impact on the quality of the educational experience as well as on their confidence in performing relevant clinical management behaviors.

Are the rules for research with subjects with dementia changing?: views from the field.

Deliberative bodies have recommended additional protections for persons with dementia included in clinical trials. This survey of experienced dementia researchers revealed that 45 to 64% considered that specific ones of these recommendations would increase subject protection, and 40 to 86% considered they would make research less feasible. The real tradeoff between protection and difficulty in conducting research on devastating illnesses needs to be confronted when new regulations in this area are debated.