University of Pennsylvania: Integrating Palliative Care into Nursing Homes During COVID-19
The University of Pennsylvania Health System has inpatient teams in all six of its hospitals. There are outpatient clinics in multiple cancer centers; an outpatient clinic for non-cancer patients with lung disease, heart disease, or renal disease; a home-based palliative care program that serves about 300 patients; and a hospice with an average daily census (ADC) of about 400 patients, including 2 inpatient units.
When a local skilled nursing facility became the first nursing home in Philadelphia to have a COVID-19 outbreak, the medical director, a U. Penn geriatrician, reached out to Nina O’Connor, MD, Chief of Palliative Care at the University of Pennsylvania Health System. He wanted to brainstorm the best ways to take care of patients in the nursing home who might prefer a less aggressive plan of care. At about the same time, two U. Penn hospitals started to see increasing numbers of ED visits and admissions for nursing home patients with COVID.
Meanwhile, the CMO of one of those hospitals was calling to see if there was any way Dr. O'Connor and her team could be of assistance. It was apparent that COVID-19 was starting to take hold in long-term care facilities locally and that the palliative care team needed to problem-solve.
It’s important to have the context that in Pennsylvania and other states, nursing homes during COVID-19 were not allowing any visitors or additional people into the facilities. Many patients had coronavirus and didn’t want to go to the hospital for life support, but they still wanted everything else. They still wanted IV fluids, labs, and X-rays. And since this was a sudden illness, their families really didn’t have a lot of time to get used to a rapid decline. Dr. O'Connor’s team was grappling with what this would mean for prognosis.
It was clear the nursing home needed a palliative care solution and that traditional hospice care wasn’t going to be the only answer. So Dr. O'Connor and her team tried a couple of different models in that first nursing home outbreak. The model they settled on was that each nursing home was assigned a palliative care physician as its consultant. That physician helped the medical director problem-solve around advance care planning and shared resources. In partnership, the palliative care physician and medical director called families to help them think through patient goals and values and priorities. This was all done virtually, either by phone or by other means, such as FaceTime or Zoom.
The second part of the solution was a large donation of iPads. U. Penn identified a donor and gave each nursing home an iPad so that the patient and the family could communicate. This was something that had been missing. The third step was assembling an amazing team of psychosocial experts from palliative care.
Assembling the Psychosocial Experts
In this case, the home palliative care and hospice programs were used as bench strength. Each family whose patient was enrolled in the palliative care pathway got an assigned social worker and a chaplain, and they also used the team’s music therapists. The team supported the patients virtually, and emphasis was put on supporting the families as well. As the patients went through their journey with coronavirus, team members were helping families with the challenges of being unable to visit and making difficult decisions ─ in some cases not to hospitalize the patient at all. If a patient passed away, the team followed up with an offer of bereavement care, even if the patient was not enrolled in hospice care. And throughout all of that, the physician also helped with symptom management and medication recommendations.
Throughout, the U. Penn team has found that the approach has to be very flexible, because if you’ve worked with one nursing home, you’ve worked with one nursing home. Every facility works a little bit differently.
Each time Dr. O'Connor's team started to work with a facility, the first step was an assessment to figure out how that facility wanted to partner. In some cases, they had weekly virtual interdisciplinary team huddles; in other facilities collaboration had to be on-the-fly. Dr. O'Connor's social workers connected with the facility social workers. Some of these facilities were so distressed with staffing challenges that they were just meeting basic needs.
In other settings, palliative care teams are used to having a daily huddle and then their interdisciplinary meeting. But these facilities are under so much stress that palliative care collaboration cannot always look just like that. The key is for the facility to have insight into what the palliative care team is working on, and for the palliative care team to know what the facility is seeing with the patient, whether that is through phone calls or a huddle. Some facilities send a regular update that gets into the chart. They make sure they have a way to connect the two teams.
Expanding the Role and Reach of Palliative Care
Two important aspects of the program are ensuring continuity and exploring ways to expand the role of palliative care. For example, there are patients in the hospital who are seen by the inpatient palliative care team. They have defined goals of care; they are not ready for hospice, but they need to go back to the nursing facility. Dr. O'Connor's team has been able to put some of those patients on the same program and give them support, and that gives the nursing homes confidence in taking those patients back so that they’ll have ongoing help with symptom management and advanced care planning.
This has been highly successful. The team has started to broaden beyond palliative care, and in the nursing homes they are working with, Penn and the department of health are partnering. They are doing site visits and starting to help nursing homes with things like infection control, testing, and other aspects of care.
“It’s a demonstration of how starting this relationship and this partnership has opened all kinds of dialogues in our community, which has been very, very positive.”
Developing and Refining a New Model
Before coronavirus, the team was starting to build palliative care services in the nursing homes. They focused on in-person consultation which was very rate limiting in terms of regions. They just hadn’t imagined that there was any other way to do it. The new reality accelerated Dr. O'Connor's program exponentially and forced the team to be a lot more creative in establishing the virtual support model.
“I think eventually we ’ll want to get back to some in-person availability, but this has opened our eyes to the fact that nursing home support can be scalable,” Dr. O'Connor said. “It doesn’t all have to be in person. We’re thinking about ways to do it on a larger scale. I think this moved us forward tremendously. The possibilities telehealth and some of these virtual tools offer will make our program a lot more scalable moving forward.”
She goes on to say, “We provided psychosocial support mostly via video, three-way video. The team would ask the facility to get the patient on, then the loved one who couldn’t visit would join, and then the psychosocial team member. For example, the chaplain would pray with and for the patient and the family would be included. I think some people are still more comfortable with telephone, and a lot of the physician work was done via telephone, less so video. But everyone has gotten much better at video. We loaded the video conferencing app BlueJeans on all those iPads that were donated so they were ready to go.”
The team was fortunate in that Penn Medicine is very system minded. When it became clear that there were a lot of patients transferring to the hospitals from the local nursing facilities, this became a system priority. They had the ability to redeploy resources to meet this need without having to justify it or get additional funding.
“I think that is a credit to the way our health system operates. We redeployed positions that were not as active in other settings, Dr. O'Connor explained. “ A lot of our surgical and cancer work decreased with coronavirus, so we focused just on confronting the virus. And that gave us some bandwidth. In addition, this didn’t turn out to be as time consuming for the palliative care physicians as they thought it would be.” It was very much doable on top of other responsibilities.
The team also drew psychosocial staff from their home palliative care program. Since most patients did not want in-person home visits for obvious reasons—social distancing—staff members were already offering their support virtually, although doing so meant they had to pivot a bit in their skills and techniques.
“CAPC course modules were foundational, as we use them to onboard all of our staff, and for leadership development and team-building,”
What Does Success Look Like?
The facilities U. Penn worked with have been grateful for the support. Dr. O'Connor and her team are working in a total of ten nursing homes at this point. They have also been able to demonstrate scalability throughout their local community, and Dr. O'Connor considers this another success factor. They're hopeful that they’ll be able to survey or do interviews with some of the nursing homes’ key leaders to understand the impact the approach had for them. As for measuring satisfaction, obviously right now they do not have bandwidth or capacity during the pandemic. But Dr. O'Connor believes this will become important down the road.