A Model to Improve Hospital-Based Palliative Care: The Palliative Care Redistribution Integrated System Model (PRISM)
Many hospitalized patients have unmet palliative care needs that are exacerbated by gaps in the palliative care subspecialty workforce. Training frontline physicians, including hospitalists, to provide primary palliative care has been proposed as one solution to this problem. However, improving palliative care access requires more than development of the physician workforce. System-level change and interdisciplinary approaches are also needed. Using task shifting as a guiding principle, we propose a new workforce framework (the Palliative care Redistribution Integrated System Model, or PRISM), which utilizes physician and nonphysician providers and resources to their maximum potential. We highlight the central role of hospitalists in this model and provide examples of innovations in screening, workflow, quality, and benchmarking to enable hospitalists to be purveyors of quality palliative care.
© 2018 Society of Hospital Medicine
Streamlining Workflow
It is common for hospitalists to oversee care for 15-20 patients at a time. Thus, they may not have the time to meaningfully engage patients to assess palliative care needs. Creating designated hospitalist palliative care teams with enhanced interdisciplinary support for patients identified using sentinel hospitalization or checklist-based tools may help to solve this dilemma. These teams may also employ lower “caps,” freeing up time for critical discussions and planning around end of life. At the University of Michigan, we are planning just such an approach, a strategy which has the additional benefit of bypassing the binary “care versus no care” dilemma faced by patients choosing palliation. Rather, patients may continue to receive treatments congruent with the goals of care in such teams.
Making Palliative Care a Standard of Care
A call for health systems to develop and implement palliative care quality metrics has emerged. Given their role in quality improvement and health system reform, hospitalists are well positioned to shepherd this imperative. Creating incentives to screen inpatients for palliative care needs and develop new homes in which to care for these patients are but a few ways to help set the tone. Additionally, developing and sharing quality metrics and benchmarks currently captured in repositories such as the Palliative Care Quality Network, Global Palliative Care Quality Alliance, and Center to Advance Palliative Care can help to assess and continually improve care delivery. Creating and sharing dashboards from these metrics with all providers, regardless of discipline or training, will ensure accountability to deliver quality palliative care.
CONCLUSION
Many hospitalized patients do not receive appropriate attention to their palliative care needs. A new interdisciplinary workforce model that task shifts to physician and nonphysician providers and pairs system-level innovations and quality may solve this problem. Input and endorsement from a wide variety of disciplines (particularly our nonphysician colleagues) are needed to make PRISM operational. The proof of concept will lie in testing feasibility among key stakeholders and rigorously studying the proposed interventions. Through innovation in technology, workflow, and quality improvement, hospitalists are well poised to lead this change. After all, our patients deserve nothing less.
Disclosures
The authors have nothing to disclose.Funding: Dr. Abedini’s work is supported by the University of Michigan National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, as well as the Un
