Palliative Care Consult Service Rotation at KP-RWC

Overview

Kaiser Family Hospitals and Health Plan (KFH/HP) of Northern California serves over 4 million members at 21 community-based hospitals, around the greater Bay Area and beyond, from San Jose to Santa Rosa and Fresno to the Sacramento area.  We are a managed care organization that contracts exclusively with The Permanente Medical Group (TPMG), which consists of approximately 10,000 full and part-time physicians.  Our service population is diverse,  and includes patients with commercial, MediCare and MediCal coverage.  Our quality of care consistently ranks in the top 5 nationally, since we are able to leverage our integrated system to deliver superior outcomes in all health categories.  Kaiser Permanente in Redwood City (KP-RWC) is a neurosurgical specialty referral center; we care for a large population of stroke and brain tumor patients from all over Northern California in addition to typical patients admitted for infection, illness, surgical needs and other cancers.

At KP-RWC, fellows are part of an interdisciplinary palliative care team (CNS, RN, social worker, chaplain), and assist in providing consultation under the supervision of an attending palliative medicine physician. Adult patients with serious illness are seen by the consult service in both the inpatient and outpatient settings and focus on advance care planning, goals of care discussions, symptom management and hospice eligibility. The bulk of the 2-week rotation is spent in an inpatient setting, in the ED, ICU and regular hospital floors of the main Kaiser hospital on Veterans Blvd in Redwood City.  One day a week, on average, will be in the outpatient setting in the adjacent Cypress Building, also on Veterans Blvd.  Interested parties can apply for additional elective time during their fellowship year.

Care Team

Attending Physicians:

• Shoshana Helman, MD
• Neelu Mehra, MD
• Mina Chang, MD
• Laura Battle, MD

Advanced Practice Providers:  Deborah Smith, MS, RN, CNS

Social Workers:  

• Monica Guzman, MSW
• Wendy Halverson, LCSW
• Sandra Hong-Li, LCSW
• Rosalind Faraone, LCSW

Chaplains: Melissa Thomson, MDiv

Clinic nurse: (position open)

ACGME Domains

Patient Care

Goals: Fellows must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems seen in patients who are experiencing serious illness. Fellows are expected to:
Competencies:

1. Perform a history and physical examination (H&P) which includes relevant information from all sources available. The H& P should address the history of the current illness, medical symptomatology, psychosocial and spiritual aspects of care, and patient/family goals of care.
2. Demonstrate the ability to provide subspecialty-level pain and non-pain symptom management including behavioral problems, at the end of life.
3. Recognize the signs and symptoms of imminent dying, provide care for the patient and family members, and demonstrate coaching skills, as appropriate, to family members regarding the dying process.
4. Provide guidance and bereavement counseling as a member of the interprofessional in patient palliative care setting.

Objectives:

1. The fellow’s H&P and progress notes will document physical, psychosocial, and spiritual aspects of care, as well as goals of care.

Medical Knowledge

Goals: 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.

Competencies

1. Learn the assessment and management of commonly seen solid tumors and hematological malignancies in a longitudinal in-patient palliative care setting.
2. Learn the management of common non-cancer diagnoses as well as the symptoms and patterns of advanced disease in a longitudinal in-patient palliative care setting.
3. Describe prognoses and disease trajectories for common illnesses.
4. Assess patients for pain and non-pain symptoms and psychosocial symptoms, including the use of validated tools to measure symptom severity.
5. Master pain management principles, including pharmacological and non-pharmacological therapies.
6. Explain the physiologic changes of imminent dying.

Objectives

1. Be able to demonstrate understanding of the underlying physiology of patient’s disease processes and symptoms by including appropriate assessments in progress notes and use evidence-based practice in choosing treatment options for patient’s symptoms.

Problem-Based Learning & Improvement (PBLI)

Goals: 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 lifelong learning.

Competencies: Fellows are expected to develop skills and habits to be able to:

1. Locate, appraise and assimilate evidence from scientific studies related to their patients’ health.
2. Identify strengths, deficiencies and limits in one’s knowledge and expertise.

Objectives:

1. The fellow will review his/her strengths and deficiencies with the supervising attending throughout the rotation.

Interpersonal & Communication

Goals: Fellows must demonstrate interpersonal and communication skills that result in the effective exchange of information and successful teaming with patients, their families, and professional associates.

Competencies: Fellows are expected to:

1. Communicate effectively with patients and families across a broad range of socioeconomic and cultural backgrounds, including demonstration of the ability to navigate difficult conversations with patients and families.
2. Communicate effectively with physicians, other health professionals, and
   health related agencies.
3. Maintain comprehensive, timely, and legible medical records.

Objectives:

1. In discussing the patient’s condition with patients and families, the fellow will use language appropriate to the educational level and culture of others, as evaluated by the supervising physician and other members of the care team.
2. The fellow will document changes in the patient’s condition or care plan within 24 hours and will alert consultants who are following the patient, either by forwarding the documentation to them or verbally notifying them.

Professionalism

Goals: Fellows must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.

Competencies: Fellows are expected to demonstrate:

1. Compassion, integrity, and respect for others.
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.
3. Accountability to patients, their families, society, and the profession.

Objectives

1. Be able to describe how the goals of care of patients and families seen on the consult service might be affected by their personal and cultural backgrounds.
2. The fellow will establish a therapeutic alliance with both the patient and the family, particularly while identifying the patient’s goals of care

System-Based Practice (SBP)

Goals: 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.

Competencies: Fellows are expected to:

1. Work in interprofessional teams to enhance patient safety and improve patient care quality.
2. Incorporate considerations of cost awareness and risk-benefit analysis in patient care.

Objectives

1. Fellows will make timely referrals to interdisciplinary members of the palliative care consult team to address psychosocial and educational needs and thus improve patient care.
2. Fellows will choose treatment regimens for symptoms using evidence-based practice and cost-effectiveness.
3. Fellows will make timely referrals to home-based programs, including hospice care, when appropriate and in line with patient and family goals

Teaching Methods

1. The primary vehicle for learning during this rotation will be through the direct provision of care under supervision of the Attending Physician in the context of an interdisciplinary team. This experiential learning will be supplemented by:

• Instruction by the supervising Attending Physician and other interdisciplinary members of the care team in the context of daily work, which may include but is not limited to mini-didactic sessions, formal and informal case presentations. Expected that at least one patient interaction per day will start with learning goals and conclude with debrief and immediate feedback.
• Direct observation of clinical care modeled by other clinicians, including the supervising physician and other interdisciplinary clinicians doing consults.
• Directed reading, both self-directed and reading as suggested by the Attending Physician or other members of the interdisciplinary team relevant to their discipline. In such reading the emphasis will be on reviewing literature that discusses the evidence base for care options as related to palliative care patients in both inpatient and outpatient care settings.

Assessment Methods

Initial meeting to determine training goals:

The fellow will have an initial meeting with the supervising Attending Physician during which both programmatic competency goals and self-directed learner goals will be discussed.

Midpoint check in and feedback

Due to the short nature of the rotation, attending(s) will provide feedback in real-time in relation to self-directed goals and listed competencies.

End-of-rotation debrief (formative feedback and block rotation evaluation):

The supervising attending will meet with the fellow at the end of the rotation to provide summative feedback, which includes input from all members of the interdisciplinary team as well as patients and families, and discuss the extent to which self-directed learning goals were achieved. During this feedback session the Attending Physician will solicit fellow feedback regarding the rotation. Fellow evaluation process and follow-up: At the end of the rotation (duration = two weeks), Med Hub sends an automated reminder to the Attending Physicians to evaluate the fellow (using a global rating scale).  The 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.

Specific evaluation methods used in this block rotation are:

Direct observation: Fellow competency will be evaluated using direct observation during patient care, discussion based on clinical care and both bedside 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 competency-based evaluation forms (standardized by GME) as a guide. The supervising attending will directly observe the fellow performing at least one major patient care intervention such as conducting a family meeting for immediate debrief and feedback per week.  In addition, the attending will provide targeted feedback daily as needed, and will observe the fellow’s presentation of recommendations to the interdisciplinary care team, referring providers and ancillary staff (such as discharge planners).

Global rating scales: Stanford has a Med Hub online evaluation system that is specifically created for confidential and standardized evaluation of fellows and faculty using survey questions with ordinal responses along with text boxes for summative feedback.