Promoting Excellence : Integrating Cancer Care and Palliative Care : Medical College of Virginia, Virginia Commonwealth University

"Compassionate care of both the living and dying has been a theme in my medical training. Palliative care is part of caring for people. It is no less important than ensuring access to good care and giving patients a shot at cure.”

--Thomas J. Smith, MD

Institution
Medical College of Virginia–Virginia Commonwealth University
Richmond, Virginia

Program
Thomas Hospice Palliative Care Unit

Year Started

Patients Seen
11-bed unit -20% occupancy first week; 80%-100% occupancy ever since.

Division Chair
Thomas J. Smith, MD
Division Chair, Hematology and Oncology (former director)
804-828-9723
[email protected]

Program Director
Kirk Payne, MD
804-828-9723

Director of Nursing Services
Patrick J Coyne, RN, MS, OCN
804-628-1295
[email protected]

Program Mission and Objectives
To bring compassionate care to those who are dying throughout central Virginia and to improve access for medically underserved people. Program objectives are:

Program Description
The Thomas Hospice Palliative Care Unit provides state-of-the-art care as part of the teaching, research and service mission of Medical College of Virginia–Virginia Commonwealth University, a National Cancer Institute-sponsored cancer center. Patients are admitted to the palliative care unit from both the medical and surgical units; most patients are indigent and without alternatives. The program also accepts patients from outpatient clinics or home. Patients often hear about the unit via word of mouth and ask about a referral, even when their physician may not be ready to take that step.

The unit also provides respite for family caregivers and sees a number of patients for same-day nerve blocks currently provided by Hospice of Central Virginia. An outpatient office sees patients one afternoon per week.

The palliative care team is composed of a physician medical director, nurse manager, clinical nurses, licensed practical nurse, patient care technicians, volunteers and volunteer coordinator, development officer, research staff, and administrative staff. Eventually, an interventional radiologist/anesthesiologist will be added to the team to do nerve blocks. Salary level is a recruitment issue.

The palliative care unit is a standard medical unit offering comprehensive care including IV fluids, chemotherapy and radiation. All referred patients are evaluated for their hospice/palliative care potential. Patrick J. Coyne, RN, MS, OCN, assesses each patient and may start palliative care even before the patient is transferred into the unit. 

When a patient enters the program, the palliative care coordinator gives the patient and/or family a tour of the unit. The patient interacts with team members as needed; most patients will also see a social worker and chaplain. The family interacts with the nurses all the time and with the doctors on rounds and by phone; the chaplain visits at least twice a day. The primary medical team also is strongly encouraged to stay involved with the patient. 

Historical Perspective
In 1994, Thomas Smith, MD, and Coyne identified palliative care as a major need in their academic health center. In 1989, the center had launched a rural cancer outreach program with emphasis on both curative and palliative care. This program had been very successful and influenced Smith’s and Coyne’s decision to pursue a palliative care program.

The Medical College of Virginia–Virginia Commonwealth University has a commitment to serving all and a tradition of letting innovators develop new programs. Smith and Coyne involved hospital decision makers from the beginning and openly shared with them the risk and benefits of the proposed program. A number of leaders, including the hospital CEO and COO as well as the director of oncology nursing gave their enthusiastic support to Smith and Coyne.

To build their case, Smith and Coyne monitored the number of patients needing care by taking a weekly census of dying patients. In 1995, they did an audit of 20 patients who had died in the hospital and documented variations in quality of care and resources used. They found that high-tech, low-reimbursed care was being used when low-tech care was needed.

Smith and Coyne gave regular updates to the medical school dean, university president and heads of various physician groups—especially during lulls in program development.  They continue to get on as many administrative agendas as possible in order to give financial updates that demonstrate the program breaks even.

Smith and Coyne also obtained grants to show external endorsement of their program concept. Funding came from the Jessie Ball DuPont Fund, which had already supported the rural cancer outreach program. Additional funding came from the Project on Death In America and from Thomas Hospice, Inc.

The challenges Smith and Coyne faced along the way range from program delays due to lack of available space to lack of decentralized decision-making authority among the hospital, university, medical school, cancer center, department of internal medicine and university physician groups.  In addition, they faced the skepticism of administrators who feared such a program might present financial barriers down the road. Because they had no financial forecasting tools, however, they could not prove that a palliative care unit would break even or save money. Smith and Coyne realized that to succeed they would need publishable research and/or a clinical education track.

Smith and Coyne continue to overcome barriers with persistence and by insisting palliative care is the right thing to do. They firmly believe that when palliative care is placed in the hands of people who like to do it, money can be saved in the long run. In addition, having a low-cost palliative care unit to care for patients who are already in the hospital frees up standard medical-surgical beds for other patients.

Among Smith’s and Coyne’s ongoing frustrations, however, are the inability to cure more patients; the inability to relieve symptoms completely in a small number of patients; the lack of universal health care, which tends to concentrate indigent care at one place; the undervaluing of palliative care by insurers, especially those that recognize the existence of the palliative care unit but pay only hospice per diem rates rather than a DRG rate for advanced care; and the unrealistic expectations of some patients and families.

Research
Thomas Smith and his program colleagues want to see if they can improve the quality of palliative care by concentrating it in the hands of people who prefer to provide it, thus reducing unnecessary use, cost and inconsistency in care. Their hypothesis is that total resource use and cost of daily inpatient care can be reduced by increasing volume of patients per practitioner—in other words, high clinical volume equals better care.  Program investigators have submitted five abstracts to ASCO on research done at least in part in the palliative care unit.

Topics being studied include:

Education
First-year medical students’ ethics curriculum includes palliative care. The hematology-oncology course includes management of the dying patient. In the second year, family members discuss their experiences with end-of-life care with students. The third year includes lectures on palliative care for students on all medical services as well as for interns and residents. During grand rounds in affiliated services (e.g., surgery), the importance of good palliative care is explained so that students know whom to call when they need assistance.

Through ASCO, Smith and his colleagues are teaching oncologists nationally that symptom control is a part of being a good cancer doctor. They have compiled a list of the 29 most important aspects of symptom control and are developing 10- to 15-minute, information-dense learning modules for each topic for posting on the ASCO Web site.

Smith and his colleagues also take every opportunity they can to reach out to churches, retirement communities and assisted living communities with education about living wills, etc.

Partnerships
Thomas Hospice joined the program after it lost its home at a hospital purchased by Columbia/HCA. Thomas Hospice supplies administrative support, education and training programs for hospice volunteers, and financial support. The program also contracts with local hospices to hospitalize their patients needing inpatient care.

Marketing
Marketing is still in the planning stage.

Funding
Thomas Hospice Palliative Care Unit is funded by clinical revenue (70%), grants (10%), hospital support (10%), charity (5%) and endowments (3%).

Vision
Thomas Smith’s vision includes:

Smith believes that palliative care is not so medically challenging that physician assistants, nurse practitioners and nurses could not do a good job of it by using algorithms.

A National Perspective
Elements and Measures of Program Success

Necessary Steps

What I Wish I’d Known Then . . .

“Understanding doctors’ current referral patterns is probably more important than making major attempts to change them. I have learned to put an inpatient unit where people will want to go—make it geographically and physically attractive. In addition, I wish I had known more about budget forecasting models.”

--Thomas J. Smith, MD


This descriptive summary is based on an interview conducted by Jane Grant Tougas with project staff in January and February 2001.

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Promoting Excellence in End of-Life Care is a National Program Office of The Robert Wood Johnson Foundation dedicated to long-term changes in health care institutions to substantially improve care for dying persons and their families. Visit PromotingExcellence.org for more resources.

Promoting Excellence