Change of Code Status
Code status and changes in codes status data were collected. Of 462 individual patients prior to or at the time of palliative care consults, 43% were full code, 4% limited code, 8% unknown status, and 45% Do Not Resuscitate. After palliative care consult, 61% of the patients who were previously full/limited/unknown converted to do not resuscitate and do not intubate status. In total, 79% of patients seen by palliative care had a confirmed code status of Do Not Resuscitate and Do Not Intubate status after consult.
Discussion
In our first year, our palliative care program exceeded the expected number of inpatient consults, corresponding with a penetration of 3.7%. With the increase of funded FTEs, preliminary data shows that the department’s penetration continues to rise remaining consistent with the data and expectations [18]. During the second year, it is anticipated that over 600 inpatient palliative care consultations will be performed with an estimated penetration of 4%. This increasing penetration reflects the rising utilization of palliative care within our hospital. Since inception of the program, the service has expanded into an outpatient clinic 2 days per week. The palliative care clinic is staffed by a registered nurse (funded 0.6 FTE) and covered by the same physicians and physician assistant providing the inpatient services. The department acquired an unfunded but designated chaplaincy volunteer to assist with patients’ spiritual needs. We believe that the success of our program during the first year was related to multiple factors: a focus of integration and education by the palliative care department, health system administration buy-in, and identification of surrounding community needs.
In addition to patient care, our palliative care department also prioritizes “tangible” impacts to better establish our contributions to the health system. We have done this through participation on hospital committees, hospital policy revision teams, and by developing innovative solutions such as a terminal extubation protocol and order set for our ICU. The health system and its administration have recognized the importance of educating nursing and physician staff on palliative care services, and have supported these continued efforts alongside our clinical obligations.
Concurrent with administration buy-in, financial supports for our palliative care services were initially supplemented by the health system. Our department understands the importance of recognizing limitations of resources in communities and their hospitals. In efforts to minimize the department’s impact on our own health system’s financial resources, we have strived to offset our costs. We helped the hospital system meet pay-for-performance palliative care metrics set by the large local insurers resulting in financial hospital reimbursement valued at $600,000 in 2016.
The question of how the program may translate into other communities raises a major limitation: the homogeneity our population. The community surrounding the hospital is primarily Caucasian, with minimal representation of minority populations. While the patient population seen by our palliative care team is reflective of our surrounding county, it does not represent Medicare FFS beneficiaries on a national level or many other types of community hospitals across the country. Variations of ethnicity, age, diagnoses, and faith are fundamental, which highlights the importance of understanding the community in which a program is developed.
The rising trajectory of our palliative care service utilization has prompted a discussion of future endeavors for our program. Expectations for a continued shortage of hospice and palliative care physicians [19] and concerns for practitioner burnout [20] underlie our thoughtful approach to expansion of inpatient and outpatient services. At this time, potential projects include a consultation trigger system and incorporation of palliative care providers in ICU rounding, as well as possible expansion of outpatient services through implantation of an advanced practitioner into surrounding nursing homes and primary care offices.
We have found a growing utilization of our program at Butler Health System. Our first year experience has highlighted the importance of identifying community and hospital administrative champions as a foundation. Additionally, understanding the specific characteristics of one’s surrounding community may allow for improved integration and acceptance of palliative care in a community setting. Our program continues to work with the health system, community, and philanthropic organizations to expand the ever-growing need for palliative care services.