1. Owens, Darrell PhD, RN, CHPN

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Starting an Interdisciplinary Palliative Care Team

Q: The hospital I work for has a small 15-bed palliative care unit and is considering starting an interdisciplinary team to visit other units in the hospital with the hope of identifying patients who could be better served by a palliative approach versus the standard medical/surgical approach. Any tips or suggestions as we look toward starting a team? -Forward-Looking RN


A: Congratulations on taking the first step toward improving care and services for people at the end of life in your institution. Based on your question, it sounds like you are considering the development of a Palliative Care Consult Team. A consult team allows patients and staff members to benefit from palliative care services and support wherever they are within an institution. Assuming this is the approach you are considering, there are several major issues to be addressed before any attempt to implement your plan.


First and foremost, you must have a thorough understanding of your institution's philosophy of end-of-life care. Second, you must know and understand your institution's business culture (eg, what services is it best known for, what does it market to the public). Although these questions may seem trivial, knowing the answers can be critical to the successful implementation of a palliative care service. Does your institution aggressively market oncology, cardiac, or obstetric services? Does it advertise and promote a "cure" culture? If the answer to these questions is yes, the institution may not want to directly support (or market) a palliative care program, because it can be seen as a direct contradiction to its public image of health and cure.


To find an answer to these questions, you should examine the institution's current commitment to end-of-life care. Does it offer support or continuing education for physicians and staff related to palliative care? Does it currently have an inpatient hospice or palliative care unit? Is there a spiritual care department? What type of support is offered to families whose loved ones die in the inpatient setting (eg, bereavement groups)? In your case, there is an existing palliative care unit. The presence of the unit reflects the institution's recognition that end-of-life patients have special needs.


Another important cultural consideration is the physician's role in your institution. Are you part of an academic medical institution, and, if so, what postgraduate residency programs are in place? What is the role of the attending physician (eg, salaried faculty, private practice, or both)? If your institution is a private facility (profit or not-for-profit), is there a hospitalists program, do attending physicians follow their own patients, or both? The answers to these questions are important if you are to gain the support you need from attending physicians. Educating and working with your medical staff will help to avoid issues of "turf" and increase your chances of physician buy-in.


Once you have addressed the previous issues, you can begin to explore exactly what type of consultation services you hope to provide. The answer to this question will help you to identify the composition of your interdisciplinary team. Again, there are several significant issues for consideration. Will your consultation team include a physician or nurse practitioner? If so, will he or she bill for services? If the answer is yes, you will need to take additional steps to identify how the billing process will work. I strongly suggest that you gain access to someone knowledgeable in Medicare Part B billing.


Some programs use clinical nurse specialists or certified hospice and palliative care nurses as primary consultants. In this model, the services are not billable and, therefore, require funding support from the institution. A true palliative care team is interdisciplinary and should have access to spiritual and social work support. In most areas, these services are also not billable; however, in certain situations, counseling services provided by a licensed medical social worker are reimbursable. Because your institution currently has a palliative care unit, depending on staffing issues, you might have the opportunity to reallocate some of your current staff's time to the new service.


Now that you have explored your institution's culture surrounding end-of-life care and determined the composition of your team, you must determine what type of services you will provide, how often you will provide them, and when the team is available. Once your team is assembled, you will need to determine what type and level of service you are going to provide. Will the team conduct one-time only consultations, or will you follow someone throughout his or her hospitalization? Will your service be available to people in the outpatient setting? Will you provide ongoing case management services? Finally, will the service only be available during "normal business hours," or will someone be available 24 hours a day, 7 days a week? Other details to be worked out include the referral process, which team member will do the initial consultation, how you will report back to the referring provider, and how the documentation/record keeping process will work. Last, but certainly not least, how will you market your program to physicians and staff?


The information presented here is by no means an all-inclusive or exhaustive list of "how to start a palliative care service." It is based on my experience of doing exactly what you are attempting to do. Understanding your institution's culture, the role the physician plays within your institution, and knowing who the "palliative care champions" are within your institution are the strongest tips I can give you for the successful development of your program.