Resources to Manage Complex Symptoms with Palliative Care

Recently Dr. Daniel Ray, Medical Director of Carolina Caring’s Palliative Medicine Program spoke to a local group of healthcare providers about the services Carolina Caring offers as well as some of the outcomes that may be important to you and your patients. 

Palliative Medicine Services
Carolina Caring offers high quality, consultative, home-based palliative medicine throughout a 12-county region in a variety of settings including hospitals, nursing centers, assisted living facilities, patient homes and palliative medicine clinics. Its core services include expert symptom management, clarification of goals and emotional support and resources.

A Consultative Approach
Its providers are very skilled in communication and do a lot of advance care planning, which is focused not as much on actual documents but on difficult in-depth conversations with people with serious illness around what they value in life and the quality of life that’s acceptable to them. Carolina Caring providers then try to pair those values and goals with medical treatments that are available and let patients make decisions appropriate to those values.

A Team Approach
The services are offered with a team approach that includes nurse practitioners, nurses, social workers, and spiritual counselors who provide psychosocial and caregiver support as well as help with the planning of end-of-life care and a referral to hospice if indicated.

Benefits of Palliative Medicine
There’s a lot of available literature around the core benefits of palliative medicine in terms of decreasing symptom burden, improving quality-of-life, decreasing hospitalizations and improving mood. When you put all that together, you’ll find that palliative medicine typically lowers healthcare utilization and subsequently the cost of medical care, which many insurance companies are positive about.

Recommended by Esteemed Healthcare Organizations
Palliative medicine has been supported and endorsed by multiple professional organizations including the American Thoracic Society, American College of Cardiology, and American Heart Association. Additionally, the clinical oncology clinical practice guidelines now have palliative medicine embedded in their recommendations.

How to Refer a Patient
Referring a patient to Carolina Caring’s palliative medicine program is simple - contact a member of our team and provide a community palliative medicine consult by phone, fax or EMR direct message. A nurse care manager will then complete pre-screen education with the patient and place two phone calls – the first call is to the patient by a nurse to determine the patient’s needs and talk about our services; the second call is to the referring provider’s office to determine specifically what type of services that interest them.

Collaboration with Primary Care
It’s very important that our services are provided in collaboration with the primary provider. We do not take over care, but rather we offer a consultative service and negotiate about who will handle symptom management, provide prescriptions and follow up with the patient.  

Intensive Stratification Program
The patient is then seen. Patient prioritization is based on an intensive stratification program. A high intensity level includes those patients who have uncontrolled symptoms - if there is high stress for the caregiver or patient or if the patient has recently been hospitalized or discharged from a facility. Our goal would be to see those patients very quickly to help decrease the risk for readmissions.

How Quickly are Patients Seen?
Providers typically see patients within two weeks of being referred via telehealth or in person. A nurse care manager also follows up by phone on a regular basis, usually weekly, with a very proactive approach to determine a patient’s needs.

Levels of Intensity
A medium and low intensity stratification also helps to determine how often we see patients, which varies based on those intensities. The low intensity patients are typically stable and their advance care planning is complete. However, they may have a high risk for decompensation so we typically follow them every 2 to 3 months with very proactive nursing calls in between visits to make sure we identify problems before they happen.

Partnerships
Carolina Caring has partnered with other agencies like Carolina Oncology Specialists to embed palliative care services within the office, which allows patients to see their palliative medicine provider at the same time or shortly after their oncology appointments.

Coordination of Care
We also help coordinate care and look for symptoms - both disease specific symptoms and treatment symptoms that have arisen - then assist with the palliation of those symptoms. This occurs in collaboration with the oncologists as we discuss individualized goals of care centered around patient and family values.

Outcomes
Carolina Caring has presented some of its findings with this collaboration which include higher patient satisfaction in those who received palliative care as opposed to those who didn’t. We also found that those who went to hospice were on hospice service longer, indicating the referral was done in a timely fashion. And very importantly the MIPS outcomes for these groups were significantly better in terms of chemotherapy within the last 14 days, hospice referrals, pain management, and ED visits. All these were improved compared to those who did not get palliative medicine, which clearly represents a win-win for the provider practice and the patient.

Another collaboration to highlight is with Advanced Home Care. This was a program that developed over the course of several years starting in 2016. By focusing on high-risk patients at Advanced Home Care and providing palliative medicine services, we helped to decrease early admission and improve satisfaction with families and patients.

In both of these collaborations we had improvement in quality of life, satisfaction with services and the ability for patients to successfully remain at home, which many prefer.

For more information about Carolina Caring’s palliative medicine program or to make a referral, please visit CarolinaCaring.org/palliative-medicine or call 828.466.0466.