Saturday, January 9, 2010

The Unofficial Role of a Community Chief Palliative Care Officer

In a recent post (see here) I commented on the exemplary performance of Susquehanna Health System (in Williamsport, Pa.) in its end-of-life care practices, according to the DAI Palliative Care Group Hospital Performance Profile. In researching communities and health systems whose palliative practices have earned them an A grade, we're finding several common attributes. One of these attributes is the presence (usually unofficial or sometimes formalized) of a chief palliative care officer. Below are excerpts of an interview with Alexander Nesbitt, MD, chief of palliative care and hospice for the Susquehanna Health System, which appeared in a recent issue of HPM Practitioner.

Dr. Alexander Nesbitt was an established family practice physician and very part-time hospice medical director in Williamsport, PA, when he heard a 2003 presentation by Dr. Diane Meier, director of the Center to Advance Palliative Care (CAPC). "I had never heard of palliative care, but I became convinced that it was a really good idea, and that somebody in Williamsport should do it." He attended the Program in Palliative Care Education & Practice at Harvard Medical School ( and began working toward board certification in HPM, earning that credential in 2004. He pursued an expanded role in Susquehanna Hospice and started advocating for a palliative care consultation service at 180-bed Williamsport Hospital & Medical Center. Both belong to the local Susquehanna Health System."The idea of starting a new program, which included hiring a full-time nurse practitioner to staff it, was an uphill push. I had to convince the hospital's administration that we should spend the money, even though the system was undergoing financial difficulties. Fortunately, CAPC has highly practical tools to use, well adapted to just that purpose." Dr. Nesbitt is an employee of the health system, which employs about half of the physicians in its region. "I had been working with administrators every step of the way, persuading them of the importance of this work - for patients and families, as well as for the system - and sharing outcomes data." When it came time to transfer full-time to hospice and palliative care, the various responsible parties were ready to sign off on the change. Dr. Nesbitt's salary is based in part on billing income from palliative care and inpatient hospice consultations, annualized, as well as an hourly rate for dedicated administrative responsibilities, which amount to nearly half of his roughly 50-hour week. "Although initially I wasn't so sure, I felt I could set it up piece by piece, and make a job of it," with the combination of hospice and palliative care a good package for the system, he says. "There's increasing information out there that this work is beneficial for the patient and family, for the reputation of the hospital, for customer satisfaction, for the bottom line, and for readmission rates."
In the beginning, Dr. Nesbitt took the lead on hospital palliative care consults, but as the program established its credibility, the nurse practitioner now makes over half of the visits. Another palliative care physician joined the team in 2007 and sees patients in affiliated, rural Muncy Valley Hospital, 10 miles away, and in the region's nine long-term care facilities. In addition to the hospital-based nurse practitioner, there is a second nurse practitioner based in the nursing homes, and an advanced practice nurse who sees patients in nursing homes and coordinates professional education events."Within the (HPM) team, each of us has a primary base, but we also work to float extra team time to wherever it is needed," he explains. The five members meet monthly to discuss practice issues. Growing demand for services is a problem, and the team tried to manage growth in sustainable ways while it extended services into the long-term care setting. Recently, it was decided to limit weekend palliative care consults to emergency cases only. "Sometimes we're really busy on the weekends, so we're working to make that part of this work more manageable," Dr. Nesbitt says. Dr. Nesbitt starts a typical workday by rounding on patients in the inpatient hospice unit, and then, depending on demand for palliative care that day, goes to the hospital. He makes occasional home visits to hospice patients and sees some patients in his office in the medical building. So far there is no formalized outpatient clinic setting or schedule for palliative care, although that may change in the next year, perhaps in conjunction with the system's Cancer Center. Dr. Nesbitt takes night and weekend call every third week, and he also meets regularly with various administrators within the health system's organizational chart. He spearheaded a POLST (physician orders for life-sustaining treatment) initiative in the region, working with the hospitals and nursing homes. The State of Pennsylvania does not give legal recognition to POLST, but a study group is working toward initiating a statewide form. He also chairs the hospital's ethics committee.

Surely, there are many factors contributing to the success of health systems and communities in their provision of late-life care to their patients and residents. I don't mean to ovrsimplify, but it's becoming apparent to us that the role of full-time HPM physicians is one of those influences.
I'm interested to learn of similar examples. Or, am I exaggerating the influence of HPM physician practices?

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