Using Quality Improvement to Increase Access to Palliative Care

Abstract

PURPOSE: As part of a larger effort to integrate palliative care into a cancer center, we identified barriers to palliative care referral for patients with breast or gynecologic cancer and developed a pilot program to improve access to palliative care services. METHODS: We developed a multidisciplinary steering committee to uncover barriers to palliative care referral and developed a pilot program, called the Warm Handoff. Through ongoing collaboration and midpilot feedback sessions, we identified several additional barriers and opportunities to increase access to palliative care. RESULTS: Clinicians used the initial Warm Handoff process only 20 times over a period of 7 months. Of those calls, 10 were for issues outside of those that the Warm Handoff pilot was intended to address. During the pilot, we identified lack of access to urgent visits and clinician telephone availability for clinical case discussion as additional barriers to access. Increased collaboration led to the creation of a clinical provider of the day (CPOD) care model, which allowed for a notable increase in the capacity to see urgent consults. After this intervention, we observed an average of 19 patients seen urgently per month. In addition, there was a trend toward increasing referrals from breast oncology after the initiation of the CPOD. CONCLUSION: A CPOD model, developed via close oncology/palliative care collaboration, resulted in increased utilization of palliative care services.

An evidence-base for the implementation of hospital-based palliative care programs in routine cancer practice: A systematic review

“…The 16 included studies ( Table 3 ) largely originated in high-income countries including the United States (US), 30 , 31 , 36 , 35 , 39 , 42 Canada, 33 , 34 , 37 , 41 United Kingdom (UK) 38 and Europe including Hungary, 7 Germany 32 and Netherlands 29 and Italy 28 One study was conducted across multiple European countries 40 ( Table 3 ).…”

“…the palliative care pathway was started only at a median of 33 days before death 3. Lally et al 30 JCO Oncology Practice To uncover barriers to palliative care referral.…”

“…The availability of dedicated palliative care specialist staff was key to the success of programs, 36 including the ability to respond to urgent consults and the availability of clinicians to discuss challenging cases. 30 A designated 'clinical provider of the day' programme allowed for a noteworthy increase in the capacity to see urgent palliative care consults with an average of 19 patients seen per month. 30 • Clearly defined roles There was a generalised perception amongst oncologists that the roles of palliative care clinicians were as 'comanagers' and 'consultants' 42 with the need for clarity emphasised around the roles and responsibilities of clinicians.…”

“…30 A designated 'clinical provider of the day' programme allowed for a noteworthy increase in the capacity to see urgent palliative care consults with an average of 19 patients seen per month. 30 • Clearly defined roles There was a generalised perception amongst oncologists that the roles of palliative care clinicians were as 'comanagers' and 'consultants' 42 with the need for clarity emphasised around the roles and responsibilities of clinicians. 34 Cancer-directed treatments were perceived to be the main domain of the oncologist, while pain and symptom control, and care for the patient and their carer were identified as the primary role of palliative care.…”

Outpatient palliative care referral system (PCRS) for patients with advanced cancer: an impact evaluation protocol

“…In summary, the best ways to address earlier PC needs identification, timely access to outpatient PC and also to overcome barriers to integration with oncology are still unresolved issues, and yet late referral is considered to be a significant barrier in many cases 28 32–36…”