North Florida/South Georgia Veterans Health System Description of Institution and Program

Advanced Illness/Palliative Care Program (AIPC)

Description of Topic

The Advanced Illness/Palliative Care (AIPC) Program started as a two year project to evaluate the effectiveness of Telehealth (text messaging devices and video phones) as a means to provide care coordination to palliative care patients. The goals of the project were to manage the holistic health care needs of palliative care patients two years before needing hospice, reduce ER and hospital stays, provide increased support and education to patients and caregivers and foster an earlier referral/admission to hospice. The AIPC team is a trans-disciplinary team including an ARNP, Chaplain, LCSW and clerk. The ARNP and Chaplain are the primary members of the AIPC team. Patients in the AIPC program are monitored at home daily using technology that enables them to answer questions about current symptoms, coping ability, spiritual needs, caregiver burden, as well as receive education related to their disease process. The AIPC team uses this information to inform the patient's healthcare provider of developing problems or needs. The AIPC team, are the eyes and ears of the provider while the patient is at home. The purpose is to address needs as early as possible and to provide the right care, at the right time and in the right place. The technology enables the team to monitor symptoms, trend data, and to provide patient education related to end stage disease processes which includes CHF, COPD, HTN, Malignances, and DM. The expertise of medical and spiritual practitioners is applied to all aspects of the program. The Advanced Illness/Palliative Care program is in its fourth year and has been mainstreamed into programs offered by the North Florida/South Georgia Veterans Health System. On average the AIPC program has 100 patients enrolled. To date the program has served approximately 300 patients. Data for the program has consistently shown cost savings and high levels of patient and caregiver satisfaction.

Impact on Program

Cost savings FY2007: N=58; 6 month pre-AIPC enrollment ER and Bed Days of Care cost: $799,860; 6 month post-AIPC enrollment ER and Bed Days of Care cost: $167,205; Medication compliance for all pts using technology: 98%; Patients reporting improved understanding of medical condition: 89%; Patients reporting increased satisfaction with communication with their provider: 82%; Improved Self Management. Patients indicating they feel more connected to their provider: 92%

Lessons Learned

Out-patient palliative care can be effectively provided to patients living in a rural setting. Partnerships within-patient palliative care teams and other related departments are essential to the success of the program. Having a champion in oncology would be ideal. There continues to be a need to educate providers on palliative care. Continual marketing of the program is a must.