Outpatient Training During Hospice and Palliative Medicine Fellowship: A National Survey.

CONTEXT: Outpatient palliative care (PC) has strong evidence demonstrating impact across serious illnesses, resulting in growing demand for skilled outpatient PC clinicians. However, there is limited literature examining the existing state and quality of outpatient PC education during postgraduate training. OBJECTIVES: Characterize the current state of outpatient training in United States (US) Hospice and Palliative Medicine (HPM) physician fellowships and elicit perceptions regarding quality of outpatient PC education. METHODS: A cross-sectional survey of US adult HPM fellowship program directors (PDs) or their designee conducted between March and July, 2023. RESULTS: Of 161 programs, 85 participated (53% response rate) with representation across all US regions. HPM fellows spend a median of 4.8 weeks in outpatient PC compared to 24 weeks inpatient PC and 10.5 weeks in hospice settings. Over half (51%) of fellows saw outpatients from primarily one disease type with limited exposure to patients with other serious illnesses. Across programs, fellows' clinic structure, interdisciplinary team composition, and didactic experiences varied. On a 5-point rating scale, PDs reported significantly lower quality outpatient versus inpatient training (mean rating: 3.58 vs. 4.62, P<0.001) and perceived fellows as less prepared for independent outpatient practice upon graduation (mean: 4.06 vs. 4.73, P<0.001). CONCLUSION: Our survey of US HPM fellowships identified multiple gaps between outpatient and inpatient PC education and training during fellowship and raises concern about the adequacy of outpatient PC training. To prepare the HPM workforce to meet the diverse needs of seriously ill populations and ensure adequate access, outpatient PC training requires reform.

A Web-Based Peer Support Network to Help Care Partners of People With Serious Illness: Co-Design Study.

BACKGROUND: Care partners of people with serious illness experience significant challenges and unmet needs during the patient's treatment period and after their death. Learning from others with shared experiences can be valuable, but opportunities are not consistently available. OBJECTIVE: This study aims to design and prototype a regional, facilitated, and web-based peer support network to help active and bereaved care partners of persons with serious illness be better prepared to cope with the surprises that arise during serious illness and in bereavement. METHODS: An 18-member co-design team included active care partners and those in bereavement, people who had experienced serious illness, regional health care and support partners, and clinicians. It was guided by facilitators and peer network subject-matter experts. We conducted design exercises to identify the functions and specifications of a peer support network. Co-design members independently prioritized network specifications, which were incorporated into an early iteration of the web-based network. RESULTS: The team prioritized two functions: (1) connecting care partners to information and (2) facilitating emotional support. The design process generated 24 potential network specifications to support these functions. The highest priorities included providing a supportive and respectful community; connecting people to trusted resources; reducing barriers to asking for help; and providing frequently asked questions and responses. The network platform had to be simple and intuitive, provide technical support for users, protect member privacy, provide publicly available information and a private discussion forum, and be easily accessible. It was feasible to enroll members in the ConnectShareCare web-based network over a 3-month period. CONCLUSIONS: A co-design process supported the identification of critical features of a peer support network for care partners of people with serious illnesses in a rural setting, as well as initial testing and use. Further testing is underway to assess the long-term viability and impact of the network.

Impact of Implementing Serious Illness Conversations Across a Comprehensive Cancer Center Using an Interdisciplinary Approach.

BACKGROUND: Gaps in communication of end-of-life care preferences increase risk of patient harm. Adoption of oncology practice guidelines advocating serious illness communication for patients with advanced cancer is limited. OBJECTIVES: (1) Increase Serious Illness Conversation (SIC) use across oncology teams via an interdisciplinary quality improvement (QI) approach and (2) assess patient reported shared decision making (SDM) experiences with clinicians engaged in SIC implementation. DESIGN: QI methodology was applied to spread the implementation of SIC across 4 oncology teams. CollaboRATE scores were used to evaluate patient reported outcomes of SDM for patients with advanced cancer. SETTINGS/SUBJECTS: The SIC QI initiative was a component of the Promise Partnership Learning Health System (PPLHS) piloted in the Dartmouth Cancer Center, Lebanon, NH, USA. MEASUREMENTS: (1) The percentage of eligible patients with documented SIC and (2) a comparison of a patient reported measure of SDM (CollaboRATE) among SIC eligible patients in encounters with providers who took part in the implementation versus those who did not. RESULTS: Oncology teams screened a total of 538 patients, identified 278 eligible patients, and completed 144 SIC conversations. The teams improved the proportion of documented SIC among eligible patients from near 0% to a collective frequency of 52%. For clinicians' top-box CollaboRATE scores, a chi-squared test demonstrated a statistically significant association between providers implementing SIC into practice and patient reported shared decision making (.16, p = .031). CONCLUSIONS: This approach allows for tailoring of iterative improvement cycles to mitigate barriers and improve the practice of SIC among oncology teams.

Adapting the Serious Illness Conversation Guide for Dementia Care.

Introduction: Advance care planning (ACP), a critical component of quality dementia care, is underutilized due to lack of clinician comfort and the challenging nature of ACP in this context. The Serious Illness Conversation Guide (SICG) is a well-validated clinician-facing tool, developed with patient and clinician input, to facilitate ACP. The aim of this project was to adapt the SICG for dementia for the first time to promote high-quality ACP. Methods: This study uses a mixed-methods approach to adapt the SICG tool for use in dementia care. Experts with relevant clinical, ethical, and topical knowledge were interviewed to develop alterations to the SICG for dementia care. Patients and caregivers were shown a mock interview of the adapted SICG for dementia (SICG-D) to elicit feedback. Results: 8 relevant experts were interviewed. Adaptations included topical alterations to make the conversation more applicable to dementia as well as alterations to the structure of the conversation to accommodate the patient-caregiver dyad. Twenty interviews were conducted with 14 patients and 18 caregivers (either together or separately). A thematic content analysis of interview transcripts demonstrated positive impressions of the tool. In anonymous survey results, 94% reported a positive impression of the conversation and 89% endorsed incorporation of the adapted guide into dementia healthcare. Conclusion: This paper presents the SICG-D, an adapted version of the SICG for use in dementia care. This guide leverages the strengths of the SICG to promote values-based ACP conversations and has been adapted to better facilitate patient-caregiver-clinician triadic communication.

Harnessing the Collective Expertise of Patients, Care Partners, Clinical Teams, and Researchers Through a Coproduction Learning Health System: A Case Study of the Dartmouth Health Promise Partnership.

The coproduction learning health system (CLHS) model extends the definition of a learning health system to explicitly bring together patients and care partners, health care teams, administrators, and scientists to share the work of optimizing health outcomes, improving care value, and generating new knowledge. The CLHS model highlights a partnership for coproduction that is supported by data that can be used to support individual patient care, quality improvement, and research. We provide a case study that describes the application of this model to transform care within an oncology program at an academic medical center.

Low-Cost, Low-Resource Training Model to Enhance and Sustain Serious Illness Conversation Skills for Internal Medicine Residents.

Background: Funding and limited resources are barriers to required training of residents in serious illness conversation (SIC) skills. Objectives: To examine the effectiveness of a low-cost, low-resource (LCLR) SIC training embedded within a required palliative care rotation. Design: Pre-post prospective cohort study design. Setting/Subjects: Second year internal medicine (IM) residents received an LCLR three-hour training in the SIC Guide (SICG) with a single-faculty member and paired-participant practice replacing actors during a required two-week palliative medicine rotation. Measures: SIC competence checklist measured within simulated patient encounters longitudinally. Results: Twenty resident average SIC checklist scores improved from 11 (95% confidence interval [CI] 9-13) at the beginning of rotation to 19 (95% CI 17-20) at the end of rotation and 18 (95% CI 16-20) at six months after the rotation. Conclusions: LCLR SIC training for IM residents significantly increased the sustained use of basic SIC skills, but was less effective for more complex skills.

Interdisciplinary Approach and Patient/Family Partners to Improve Serious Illness Conversations in Outpatient Oncology.

PURPOSE: We aimed to increase Serious Illness Conversations (SIC) from a baseline of, at or near, zero to 25% of eligible patients by December 31, 2020. METHODS: We assembled an interdisciplinary team inclusive of a family partner and used the Model for Improvement as our quality improvement framework. The team developed a SMART Aim, key driver diagram, and SIC workflow. Standardized screening for SIC eligibility was implemented using the 2-year surprise question. Team members were trained in SIC communication skills by a trained facilitator and received ongoing coaching in quality improvement. We performed Plan-Do-Study-Act cycles and used audit-feedback data in weekly team meetings to inform iterative Plan-Do-Study-Act cycles. The primary outcome was the percent of eligible patients with documented SIC. RESULTS: Over 18 months, three clinics identified 63 eligible patients; of these, 32 (51%) were diagnosed with head and neck cancer and 31 (49%) with sarcoma. The SIC increased from a baseline near zero to 43 of 63 (70%) patients demonstrating three shifts in the median (95% CI). Conversations were interdisciplinary with 25 (57%) by oncology MD, six (14%) by advanced practice registered nurse, and 13 (30%) by specialty palliative care. We targeted four key drivers: (1) standardized work, (2) engaged interdisciplinary team, (3) engaged patients and families, and (4) system-level support. CONCLUSION: Our approach was successful in its documentation of end points and required resource investment (training and time) to embed into team workflows. Future work will evaluate scaling the approach across multiple clinics, the patient experience, and outcomes of care associated with oncology clinician-led SIC.

Implementation and Impact of a Serious Illness Communication Training for Hematology-Oncology Fellows.

Effective communication between providers and patients with serious illness is critical to ensure that treatment is aligned with patient goals. We developed and tested an implementation strategy for incorporating the previously developed Serious Illness Conversation Guide (SICG), a clinician script, into hematology-oncology fellowship training at a single US academic medical center. Between December 2017 and April 2018, we trained 8 oncology fellows to use and document the SICG. The training included associated communication skills-such as handling emotion and headlining-over 7 didactic sessions. Implementation strategies included training 4 oncology faculty as coaches to re-enforce fellows' skills and an electronic medical record template to document the SICG. We assessed effectiveness using 4 approaches: (1) SICG template use among fellows in the 12 months following training, (2) fellow confidence pre- and post-intervention via survey, (3) performance in 2 simulated patient encounters, and (4) semi-structured interviews after 12 months. Fellows successfully implemented the SICG in simulated patient encounters, though only 2 of 6 fellows documented any SICG in the clinical practice. Most fellows reported greater confidence in their communication after training. Thematic analysis of interviews revealed the following: (1) positive training experience, (2) improved patient preference elicitation, (3) selected SICG components used in a single encounter, (4) prioritize other clinical duties, (5) importance of emotion handling skills, (6) no faculty coaching receive outside training. Despite acquisition of communication skills, promoting new clinical behaviors remains challenging. More work is needed to identify which implementation strategies are required in this learner population.

Acceptability and Impact of a Required Palliative Care Rotation with Prerotation and Postrotation Observed Simulated Clinical Experience during Internal Medicine Residency Training on Primary Palliative Communication Skills.

BACKGROUND: Improving communication training for primary palliative care using a required palliative care rotation for internal medicine (IM) residents has not been assessed. OBJECTIVE: To assess skills acquisition and acceptability for IM residents not selecting an elective. DESIGN: A consecutive, single-arm cohort underwent preobjective structured clinical examination (OSCE) with learner-centric feedback, two weeks of clinical experience, and finally a post-OSCE to crystallize learner-centric take home points. SETTING/SUBJECTS: IM second year residents from Dartmouth-Hitchcock were exposed to a required experiential palliative care rotation. MEASUREMENTS: Pre- and post-OSCE using a standardized score card for behavioral skills, including patient-centered interviewing, discussing goals of care/code status, and responding to emotion, as well as a confidential mixed qualitative and quantitative evaluation of the experience. RESULTS: Twelve residents were included in the educational program (two were excluded because of shortened experiences) and showed statistically significant improvements in overall communication and more specifically in discussing code status and responding to emotions. General patient-centered interviewing skills were not significantly improved, but prerotation scores reflected pre-existing competency in this domain. Residents viewed the observed simulated clinical experience (OSCE) and required rotation as positive experiences, but wished for more opportunities to practice communication skills in real clinical encounters. CONCLUSIONS: A required palliative care experiential rotation flanked by OSCEs at our institution improved the acquisition of primary palliative care communication skills similarly to other nonclinical educational platforms, but may better meet the needs of the resident and faculty as well as address all required ACGME milestones.

Joining together to improve outcomes: integrating specialty palliative care into the care of patients with cancer.

This article addresses the misconception that patients with cancer should undergo a definitive "transition" to palliative care at some point in their trajectory, and instead proposes that a gradual shift should occur from primary palliative care provided by the oncologist to specialty palliative care when the need exists. The goal is to help practitioners identify which patients are in need of specialty palliative care, suggest when oncologists should consider making a referral, and offer a model for sharing the responsibilities of care once palliative care clinicians become involved. This model enhances the patient and family experience through improving symptom control and quality of life, and may even prolong survival. It also minimizes patients' perception of abandonment at the end of life, while reducing the risk of physician burnout in practicing oncologists. Lastly, the misconceptions of oncologists are addressed regarding how patients and families will accept the idea of a palliative care consultation, and suggestions are offered for responding to patient and/or family resistance to referral when it arises.

Improving access to palliative care through an innovative quality improvement initiative: an opportunity for pay-for-performance.

BACKGROUND: Improving access to palliative care is an important priority for hospitals as they strive to provide the best care and quality of life for their patients. Even in hospitals with longstanding palliative care programs, only a small proportion of patients with life-threatening illnesses receive palliative care services. Our two well-established palliative care programs in large academic hospitals used an innovative quality improvement initiative to broaden access to palliative care services, particularly to noncancer patients. METHODS: The initiative utilized a combination of electronic and manual screening of medical records as well as intensive outreach efforts to identify two cohorts of patients with life-threatening illnesses who, according to University HealthSystems Consortium (UHC) benchmarking criteria, would likely benefit from palliative care consultation. Given the differing cultures and structure of the two institutions, each service developed a unique protocol for identifying and consulting on suitable patients. RESULTS: Consultation rates in the target populations tripled following the initiative: from 16% to 46% at one hospital and from 15% to 48% at the other. Although two different screening and identification processes were developed, both successfully increased palliative care consultations in the target cohorts. CONCLUSION: Quality improvement strategies that incorporate pay-for-performance incentives can be used effectively to expand palliative care services to underserved populations.