Implementing Virtual Hospice: Challenge and Discovery

Topic: Palliative Care Models by Setting

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Implementation of a virtual hospice service in a large academic center:  Challenges, solutions and discoveries

Objective:  Design and implementation of a virtual hospice service as a bridge to future inpatient unit.

Methods

Strategic planning with hospital and health system leadership identified a gap in inpatient hospice services.  Plans for an inpatient unit were significantly delayed due to hospital capacity constraints.  Creation of a virtual hospice program was requested and aligned with the palliative care team and a respected local hospice agency.  Key elements included palliative care as the primary attending service, patients formally enrolled in the hospice benefit, room enhancements and 24/7 hospice team support.

Results

Implementation was staged, starting in medical and neurologic intensive care units, pre- selected by administration due to high mortality rates.  In the first seven months, with rapid roll-out, 91 patients and families were cared for, with an average length of stay of 1.0 days. Ten patients died while still in the ICU, 75 were transitioned to a ward bed and six patients were discharged.   Hospital mortality index declined by 36%.  Challenges included:  investment of non-clinical time to develop the program, lack of buy-in from multiple sectors (hospital RN’s, case management, referring MDs, palliative MDs) about potential benefit to patients and families, computer workflows, cost and workforce concerns.  Several key quality improvement areas were identified during implementation, including provider lack of knowledge  regarding the difference between hospice and palliative care, as well as varying practices in opioid dosing during terminal extubation.

Conclusions

Virtual hospice services have the potential to enhance end-of-life experiences for patients and families with anticipated hospital death, but provide significant challenges in implementation.   Key factors in the initial success of our hospice program include:  tremendous support from hospital and hospice agency senior leadership, multi-disciplinary planning, flexibility in palliative medicine faculty and nurse practitioners, identification of anticipated cultural challenges prior to implementation and 24 hour support from experienced hospice RN’s.

Author

  • Wendy L. Peltier, MD
  • Associate Professor
  • Medical College of Wisconsin
  • 9200 West Wisconsin Avenue
  • Milwaukee, MI 53226
  • (414) 805-4607

Co-authors

  • Jessica Lisinski
  • Kathy Walczak
  • Liza Thiel
  • McCracken Colleen
  • Molly Kast
  • Sandy Muchka
  • Sandy Simuncak
  • Susan Hoefs
  • Tiffany Kirchner
  • Wendy L. Peltier

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