Eytan Szmuilowicz MD Northwestern University Feinberg School of Medicine Chicago, IL

1. Eytan Szmuilowicz MD Northwestern University Feinberg School of Medicine Chicago, IL Changing Culture and Learning Lessons from PREP-CPC(Preventing Readmissions through Effective Partnerships – Communication and Palliative Care)

2. Background • Preventing Readmissions through Effective Partnerships – Communication in Palliative Care • A Blue Cross/Blue Shield of Illinois sponsored program, coordinated with the Illinois Hospital Association • Funding for multidisciplinary teams from diverse hospitals/hospital systems across the state • An offshoot of Project BOOST (Better Outcomes by Optimizing Safe Transitions)

3. PREP-CPC: The Problem(s) Inadequate patient-centered communication has consequences for the patient, his/her family, healthcare providers, and the healthcare system

4. Palliative Care: The Integrated Model Bereavement Palliative Treatment Curative Treatment Hospice Diagnosis Incurable/Untreatable Death

5. PREP-CPC: Limits of Specialty Palliative Care Demand >> Supply

6. PREP-CPC: Solution(s) Integrating Primary Palliative Care into Everyday Practice  StandardizingProcess of Open, Ongoing Communication Clarifying Prognosis and Goals of Care Matching patient goals to appropriate treatment

7. Project Goal Focus on Clarifying Goals of Care • Improving communication about and documentation of patients’ goals of care • Improving transmission of information across sites of care Anticipated improvements in patient/family care • Improving patient/family understanding of patient’s condition • Matching care provided to patient/family needs • Reducing patient/family distress around advanced illness

8. PREP-CPC: Assumption • Communication skills can be taught and learned • Mentored-implementation helps promote change • Small change will eventually lead to bigger changes

9. PREP-CPC: The Model

10. PREP-CPC: Timeline

11. Cohort Kick-off Training • Intensive 2-day program • Day 1: • Multi-modal Focus on structured goals of care conversations • Didactics and Cognitive Framework • Demonstration of a goals of care conversation • Small group reflection and practice using checklist • Individual sessions with standardized patient actor (SPA) at simulation center including feedback on performance from faculty and SPA • Opportunity to revisit identified areas of weakness until competence demonstrated

12. Cohort kick-off training • Day 2 • Quality Improvement Project Development • Didactic sessions on Quality and Primary Palliative Care • Teams designed their project • Teams presented their planned project and received feedback from faculty and colleagues

13. Mentored Implementation • Monthly update phone calls with mentor • Mentor Site Visit, months 3-6 • All-site mid-year conference call/webinar • All-site email Listserve • Year-End Reunion and Brainstorming Next Steps

14. PREP-CPC: Timeline Month 7 Month 8 Month 6 Month 1 Month 5 Month 9 Month 4 Pre-Work Month 2 Month 10 Month 3 Month 11 Mentor Site Visit Conference call Conference call Conference call Conference call Conference call Conference call PREP-CPC Conference Conference call PREP-CPC Reunion Conference Conference call Conference call Mid-Year All-group Webinar Prepare Year-End Reports Resource Exchange between Sites via CPC Listserve

15. PREP-CPC Participating Hospitals

16. PREP-CPC Trained Participants *Cohort 6 is not included in the participant characteristics table

17. PREP-CPC: Participant Confidence

18. PREP-CPC: Process Changes

19. PREP-CPC: Process Changes

20. PREP-CPC: Outcomes • Program found useful and enjoyable • Participants were more confident • Participants taught their colleagues • Teams developed new processes within their institutions (triggers and documentation) • Teams documented increased # of goals of care conversations • Palliative Care “Ripple Effects”

21. PREP-CPC: Failures XMost teams did NOT demonstrate changes in patient-outcomes or readmissions Why? • Too small a scope • Not enough time • Ineffective conversations • Lack of MD engagement • Lack of coordination across sites of care

22. Sample Projects and Outcomes • Hospital A Goals: • Decrease admissions to progressive care unit from extended care facilities • Increase number of advanced care planning discussions in progressive care unit • Increase number of palliative care consultations in progressive care unit

23. Hospital A

24. Hospital A – What worked and why? • Dynamic physician AND nursing leadership • Multi-modal training of staff • Portable document/directive • Collaboration with SNF

25. Sample Projects and Outcomes • Hospital B • Increase Advance Care Planning for Patients with Heart Failure • Developed triggers for initiation of goals of care conversations • Trained Transition Coach RNs + Trained Home Health RNs + Heart Failure Program RN’s to initiate conversations • Documented goals of care conversations for all identified patients

26. Hospital B

27. Hospital B – 30-day Readmission Rates

28. Hospital B – What worked and why? • Dynamic team leader • Synergy with other QI project(s) • Identified responsible “champions” at each site/team • Collaboration between sites of care

29. Lessons Learned #1 The right Leader and The right Team are Crucial

30. Lessons Learned #2 Develop and Support “Champions” Who have expertise and time to focus on key tasks

31. Lessons Learned #3 Make the RIGHT thing to do EASIER to do • Define “Right” • Build into existing process

32. Lessons Learned #4 Patient Outcomes willonly change if there is Coordination and Collaboration across sites and teams of care

33. Lessons Learned #5 Data Collection is Crucial • To Monitor Progress • Garner Support • Show Progress

34. Lessons Learned #6 Quality Improvement is NOT the same as research

35. Lessons Learned Quality comes from continual improvement focusing on relationships

36. A Ways to Go… • Engaging Physicians • Tailoring the teaching • Collaborating with non-Hospital providers • Engaging Patients and Families

37. Thank you for your attention!Questions or Comments?