CAPC Palliative Care Discussion Forum
Data Collection and Measurement
Hi,
I have been running a nurse consultant PC program for nearly 5 yrs now, with only a per diem nurse for back-up. I saw over 500 pts last year and am getting burned out. I have proposed hiring a PC physician a number of times, as well as expanding the team in general, without success. And yes, I have followed the CAPC advice on this to the best of my ability. I have heard, anecdotally, that a PC program is more effective with physician involvement. Is there data to back this up? Every time I ask about giving my per diem more hours to help me they ask me to show them decreased LOS. In some instances I can do this, but we usually only get called in the more complex cases in the 1st place, so looking at DRG's with and without PC does not show decreased LOS. I can show determination of goals of care and DNR status. It is harder to prove that it was my involvement that prevented an escalation in level of care, or assisted family with deciding on withdrawal of support. Administration points that out, and then, of course the final answer is "it's not in the budget."
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Data on nurse run vs physician run PC programs
I am not aware of data that compares different kinds of teams, but there are several consensus statements in the field at this time that point to the need for physician involvement on a multi-disciplinary team. See the NCP website at http://www.nationalconsensusproject.org/ and the article by Weissman et al., "CAPC PC Service Metrics" J Palliat Med. 2008 Dec;11(10):1294-1298. In some institutions there is a physician-centric culture where recommendations from NPs don't carry as much weight, and if that's the case in your hospital then you may not be maximizing your possible clinical impact in your current model.
LOS is a non-starter; you need to reframe their expectations regarding LOS. As you indicate it's something you can document for a given case (good symptom management and discharge planning can help to expedite safe & appropriate discharge for survivors in some cases) and such a vignette or case-study can be pretty compelling. But it's practically impossible for you or any other PC program to quantify any LOS impact, as we summarized in a recent article in JPM (see J Palliat Med. 2010 Jun;13(6):761-767.).
However it is definitely possible to demonstrate cost reduction across your whole case load, and to quantify that in dollars. You need to partner with a financial analyst in your hospital and match your PC consult list to the hospital data to quantify the cost-reduction that your program produces, comparing before and after costs per day per PC patient. This is done using your own actual hospital data, not just guesstimating the effect based on the CAPC calculators. One of the CAPC online (e-learning) resources (http://campus.capc.org/) gives you some instructions for how to analyze the data, and it's something we cover in great detail in a PCLC training (any level - core, consult or custom) which includes one year of post-training mentoring. See http://www.capc.org/palliative-care-leadership-initiative/overview
Such a financial analysis is often sufficient to prove that the hospital is seeing a sizable financial benefit secondary to you'all helping to improve care for the patients you see, and helps to make the case for sustaining and expanding the program to meet the existing and potential needs.
Please do let me know if this reply helps or falls short. We can't afford as a field to have people like you burning out and leaving!
- Brian Cassel
VCU Massey Cancer Center
Palliative Care Leadership Center