Fellows rotate through community hospice agencies for 6 weeks. This training is provided at Mission House (hospice care) and Vitas Hospice Care. During this rotation the fellow will be exposed to palliative care as practiced in a large community hospice. The home hospices affiliated with our fellowship program serve patients throughout the greater Bay Area with a very large average daily census. Thus the fellow gets ample opportunity to care for hospice patients with a wide array of common medical and surgical conditions in a collaborative inter-disciplinary (nursing, social-work, nutritional care, spiritual care, pharmacy) environment.
The fellow must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Fellows are expected to:
1. Provide an appropriate assessment of patients, based on a review of available medical records, and a relevant history and physical. 2. Make recommendations regarding medical management for inclusion in the hospice care plan, which incorporate an understanding of the patient’s medical history and symptomatology and an appreciation for any adjustments or modifications that might be indicated in light of care provision at home.
1. The fellow will make 25 home hospice visits during the rotation.
2. The fellow will present assessments made and suggestions for the care plan to the supervising Medical Director and, when appropriate, to the care team.
Fellows must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care. Fellows are expected to:
1. Demonstrate an understanding of both the limitations and opportunities for the provision of palliative care in the home environment, including both assessment and the use of therapeutics. Particular attention should be paid to medication choices, balancing therapeutic efficacy and ease of administration in the home.
2. Demonstrate an understanding of assessing initial as well as ongoing eligibility for hospice care for a variety of disease processes.
1. Recommendations for both assessment and therapy made by the fellow will reflect an understanding and appreciation for feasibility in the home setting.
2. The fellow will assess patients evaluated and presented in terms of prognosis and eligibility to the supervising medical director and, when appropriate, the care team.
Problem-Based Learning & Improvement (PBLI)
Fellows must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning. Fellows are expected to develop skills and habits to be able to:
1. Set learning and improvement goals.
2. Participate in the education of patient’s families, and other health care professionals during home visits as well as team meetings as documented by evaluations of a fellow’s teaching abilities by faculty.
1. At the beginning of the rotation the fellow will identify one self-directed learning goal for the rotation and present this goal to the supervising physician. Progress toward this goal will be evaluated at the end of the rotation.
2. The fellow will be observed by the supervising physician or other staff engaging in the education of patients, families, students or other health professionals at least once during the rotation.
Interpersonal & Communication
Fellows must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates. Fellows are expected to:
1. Communicate effectively with physicians, other health professionals, and health-related agencies.
2. Act in a consultative role to other physicians and health professionals.
The fellow will communicate assessments and recommendation to others involved in care of the hospice patient, including the medical director and members of the hospice care team in a manner that is clear and respectful of their relative responsibilities and duties relative to the patient.
Fellows must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Fellows are expected to demonstrate:
1. Responsiveness to patient needs that supersedes self-interest.
2. Sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation.
1. The fellow will respond promptly to requests for a home evaluation or for consultation (provided under direction of the supervising physician) with hospice staff.
2. The fellow will demonstrate sensitivity to differing customs in the home both in choice of language and behavior.
System-Based Practice (SBP)
Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Fellows are expected to:
1. Work effectively in various health care delivery settings and systems relevant to their clinical specialty.
2. Incorporate considerations of cost awareness and risk-benefit analysis in patient care.
1. The fellow will demonstrate an ability to work effectively as a member of an interdisciplinary team caring for patients in hospice, as evidenced by collegial interactions with staff in the performance of home visits and interdisciplinary team meetings.
2. Recommendations for diagnostic procedures and therapeutics will reflect a thoughtful weighing of risk and benefit for patients cared for at home and an appreciation of any cost impact on the hospice organization.
The primary vehicle for learning during this rotation will be through the direct provision of care under supervision by one of the Medical Directors in the context of an interdisciplinary team. This experiential learning will be supplemented by:
- Formal weekly fellowship didactic sessions.
- Participation in and observation of interdisciplinary care planning meetings.
- Ad hoc instruction by the supervising medical director and other inter-disciplinary members of the care team in the context of daily work, which may include but is not limited to mini-didactic sessions, formal and in-formal case-presentations.
- Direct observation of clinical care modeled by other clinicians, including the supervising physician and other inter-disciplinary clinicians making home hospice visits.
- Directed reading, both self-directed and reading as suggested by the supervising physician. In such reading the emphasis will be on reviewing literature that discusses the evidence base for care options as relate to patients being cared for at home and the nursing home under the Medicare Hospice Benefit as well as other third-party payers.
- Direct observation by the supervising attending for patient care on home visits and inter-professional team meetings.
- Each patient is presented to the supervising attending who also independently evaluates the patient.
Initial meeting to determine training goals:
The fellow will have an initial meeting with the supervising attending physician (one of the home hospice Medical Directors) during which both programmatic competency goals and self-directed learner goals will be discussed.
End-of-rotation de-brief (formative feedback and block rotation evaluation):
The supervising attending will meet with the fellow at the end of the rotation to provide formative and summative feedback, review the evaluation form with the fellow, and discuss to what extent programmatic and self-directed learning goals were obtained. Informally, the supervising physician will solicit feedback regarding the fellow’s performance from Home Hospice patients, families, and other hospice clinicians, as deemed appropriate. During this feedback session the attending physician will solicit feedback regarding the rotation.
Fellow evaluation process and follow-up:
At the end of the community hospice block rotation, Med Hub sends an automated reminder to the hospice Medical Director to evaluate the fellow (using a global rating scale) who worked in that particular rotation. Evaluations are captured and collated by the system and aggregate data for individual fellows across various block rotations is available to the program director and will be used for both formative and summative fellow evaluation. When a fellow receives a sub-par evaluation on the Home Hospice rotation an automated trigger will send an alert to the program director who will immediately take necessary remedial action as appropriate.
Specific evaluation methods used in this block rotation are:
Direct observation: Fellow competency in will be evaluated using direct observation during patient care, and the results of direct questioning during clinical care and both bedside (at the patient’s home setting) and clinical rounds based teaching experiences. Fellows will be observed by faculty during a clinical interaction and their skills will be evaluated by faculty using global rating scales and specific Home Hospice competency assessment checklists (attached). The supervising attending will directly observe the fellow performing at least one major patient care intervention such as a home visit during the month and will observe the fellow’s presentation of recommendations to the Home Hospice interdisciplinary care team.
Global rating scales:
Stanford has a Med Hub online evaluation system, which is specifically designed to evaluate fellows and faculty using survey questions with ordinal responses.
Rotation specific assessment checklists:
The hospice rotation specific checklists is specifically designed to evaluate specific competencies related to this rotation. Attending physician will use this checklist to evaluate fellows at the end of each block rotation. These evaluations will be captured using an online database and collated and used to provide formative and summative feedback to the fellow.