American Academy Of Hospice And Palliative Medicine Research Articles

A parade of firsts: J. Randall Curtis, MD, MPH modeled a future for palliative care academics

Palliative care history is short, and the history of its research is even shorter. In 1997, when I first met Randy Curtis at a Project on Death in America Faculty Scholars meeting, the field of palliative care as we now know it did not exist. The American Academy of Hospice and Palliative Medicine (AAHPM), a tiny organization, had just emerged from the even tinier Academy of Hospice Physicians. American Board of Medical Specialties board certification would not appear for nearly another decade. And, whereas our clinical and educational infrastructure felt threadbare, the palliative care research landscape was completely unstitched.

Finding the Strength Within: Increasing Spiritual Screening for Inpatient Consults with a Transdisciplinary Team (TH371A)

•Describe a multi-faceted intervention to increase documentation of spiritual screening for a transdisciplinary inpatient consult team.•Identify the transdisciplinary team as an essential asset of quality improvement endeavors in palliative care settings. The American Academy of Hospice and Palliative Medicine (AAHPM), The National Quality Forum (NQF), and the National Consensus Project (NCP) identify spiritual screening as a core element and quality metric for palliative care (PC) consults. This recommendation is based on research showing that patients want their doctors to discuss spirituality and that these discussions change patients' healthcare decisions. We sought to increase the rate of documented spiritual screening for inpatient consults at our hospital by 10% between September 2018 and May 2019 from the 2017 average screening rate of 69%. After completing a fishbone gap analysis, we developed a 4-part intervention to address factors contributing to low documentation of spiritual screening, including monthly e-mail reminders, announcements at monthly division meetings, posting “meme” reminders in our workroom, and changing the method for documenting in the electronic health record (EHR). Data from the Palliative Care Quality Network (PCQN) was used to monitor rates of documented spiritual screening out of all our team's inpatient consults. Of the 502 inpatient PC consults completed, 413 (82%) had documented spiritual screening during the intervention, representing a significant increase from the 2017 average of 69% (p<0.0001). Over the course of the intervention, there was variability in screening rate from month-to-month (range 73% to 94%). Months with the highest rates of documented spiritual screenings were months when all reminder interventions were in effect. Completion of spiritual screening requires the attention of all providers on the transdisciplinary team. A combination of gentle reminders and streamlining documentation in the EHR resulted in significant increases in rates of documented spiritual screening. Lessons learned from this quality improvement project include involving a transdisciplinary team early in the design process, utilizing the transdisciplinary team's expertise to define best practices, and developing a robust plan for collecting and reporting data.

How Should Organized Medicine Respond to Physician-Assisted Death?

Both proponents and opponents agree that wider access to high-quality palliative care and physician-patient communication about end-of-life options is the right response to the growing patient dema...

Coding and Billing Jeopardy—Play with the Experts (FR477)

•Identify the importance and rules for capturing reimbursement from three sites of community-based palliative care eligible for reimbursement.•Delineate Evaluation and Management and Time-Based service codes, including the benefits and consequences of each, including the appropriate use of Advance Care Planning codes.•State billing and coding resources. Payment for services with precise billing and coding systems is essential for revenue for palliative care programs in the community. An organization’s billing and coding system sets the foundation for reimbursement from Medicare, Medicaid, and private insurance—and ultimately the budget. Accuracy and quality of billing documentation and submission is essential, as well as monitoring code changes. Through an interactive and engaging process, this session will provide a review of the potential patient encounters eligible for billing as well as accurately capturing the delivery of services. An interdisciplinary palliative care panel—a coding expert, a palliative physician, and a palliative nurse practitioner—will provide discuss billing and coding essentials from across the spectrum. Using a game format, the session will move through a face paced look at common quandaries, pitfalls, and myths about billing and coding. Participants will learn the importance of documentation supporting codes, the benefits and consequences of Evaluation and Management and Time-Based codes, and the appropriate use of Advance Care Planning codes. Resources from the Center for Medicare and Medicaid Services (CMS), Medicare Learning Network (MLN), Center to Advance Palliative Care (CAPC), Hospice and Palliative Nurses Association (HPNA), American Academy of Hospice and Palliative Medicine (AAHPM) and National Hospice and Palliative Care Organization (NHPCO) will be highlighted. The hour will conclude with an interactive Q & A session, and useful "take home" materials.

The Quality Improvement Environment: Results of the 2016 AAHPM/HPNA Membership Needs Assessment Survey

ContextThe American Academy of Hospice and Palliative Medicine (AAHPM) and Hospice and Palliative Nurses Association (HPNA) convened the Measuring What Matters (MWM) initiative in 2013, which recommended 10 quality performance measures; yet, little is known about the quality improvement (QI) environment and implementation of the MWM among hospices and palliative care services. ObjectivesThe objective of this study was to describe the findings of the 2016 AAHPM/HPNA Needs Assessment survey exploring the QI environment among hospice and palliative care services. MethodsAn online survey was distributed to approximately 16,500 AAHPM and HPNA members, and other hospice and palliative care organizations were invited to respond. Summary data and individual write-in responses were collated and analyzed. Data analysis included generating descriptive statistics and analyzing individual write-in responses for additional information and themes. ResultsMore than 1000 responses were received. Most organizations had a designated QI leader and used an electronic medical record. Less than 50% of systems had fields for palliative care information. The top three MWM measures collected through an electronic medical record were pain treatment (66%), screening for physical symptoms (55%), and comprehensive assessment (54%). The most common barrier to implementing QI was time constraint. Most respondents had received no training and education in how to implement QI. ConclusionsThe 2016 AAHPM/HPNA Needs Assessment Survey provided important information about the QI systems and measurement environment within hospice and palliative care services. Survey insights can aid AAHPM/HPNA in developing resources to empower hospice and palliative care clinicians to make QIs that matter for their patients and families.

The Effect of Palliative Care Team Design on Referrals to Pediatric Palliative Care.

The American Academy of Pediatrics (AAP) and the American Academy of Hospice and Palliative Medicine (AAHPM) have recommended minimal standards for palliative care (PC) team composition and availability. It is unknown whether team composition affects utilization of PC. The study objective was to describe pediatric PC team composition, evaluate whether composition and availability are associated with utilization, and examine PC referral patterns. The study was a descriptive survey. Subjects were pediatric PC team directors or hospital administrators at Pediatric Health Information System (PHIS) hospitals (N = 44). The overall response rate was 86%. Teams varied in size from <1 to 9 full-time members. Average referrals per hospital bed were 0.46, range 0.05-2.13. Among individual PC team roles, referral rates were 34% greater in teams with an advanced nurse practitioner (ANP) (p = 0.07). Likewise, teams with acute pain, chronic pain, or hospice palliative medicine specialists tended to have greater referral rates (39%, 36%, and 25%), though reported differences were not statistically significant. Teams adherent to the original AAP recommendations had a 31% greater referral rate (p = 0.22). Teams available 24 hours daily had similar referral rates to those with less availability (0.47 versus 0.46 [p = 0.94]). Team composition and availability are not crucial to PC utilization. Hospitals with some personnel but not all recommended team members should create formal teams and modify them over time. The addition of team members that tend to increase referrals, namely ANPs and acute pain, chronic pain, or hospice palliative medicine specialists, should be considered.

Measuring What Matters: Top-Ranked Quality Indicators for Hospice and Palliative Care From the American Academy of Hospice and Palliative Medicine and Hospice and Palliative Nurses Association

ContextMeasuring quality of hospice and palliative care is critical for evaluating and improving care, but no standard U.S. quality indicator set exists. ObjectivesThe Measuring What Matters (MWM) project aimed to recommend a concise portfolio of valid, clinically relevant, cross-cutting indicators for internal measurement of hospice and palliative care. MethodsThe MWM process was a sequential consensus project of the American Academy of Hospice and Palliative Medicine (AAHPM) and Hospice and Palliative Nurses Association (HPNA). We identified candidate indicators mapped to National Consensus Project (NCP) Palliative Care Guidelines domains. We narrowed the list through a modified Delphi rating process by a Technical Advisory Panel and Clinical User Panel and ratings from AAHPM and HPNA membership and key organizations. ResultsWe narrowed the initial 75 indicators to a final list of 10. These include one in the NCP domain Structure and Process (Comprehensive Assessment), three in Physical Aspects (Screening for Physical Symptoms, Pain Treatment, and Dyspnea Screening and Management), one in Psychological and Psychiatric Aspects (Discussion of Emotional or Psychological Needs), one in Spiritual and Existential Aspects (Discussion of Spiritual/Religious Concerns), and three in Ethical and Legal Aspects (Documentation of Surrogate, Treatment Preferences, and Care Consistency with Documented Care Preferences). The list also recommends a global indicator of patient/family perceptions of care, but does not endorse a specific survey instrument. ConclusionThis consensus set of hospice and palliative care quality indicators is a foundation for standard, valid internal quality measurement for U.S. settings. Further development will assemble implementation tools for quality measurement and benchmarking.

Consensus development: Within general oncology practice, what constitutes high-quality palliative care delivery?

280 Background: Multiple studies illustrate the benefits of combined palliative and standard cancer care, but oncology practices need guidance to fill existing gaps in delivering high quality palliative care (PC) to cancer patients. As a first step, ASCO and the American Academy of Hospice and Palliative Medicine (AAHPM) sought to develop a consensus definition of which PC aspects are within the purview of general adult oncology practice in the United States. Methods: An ASCO and AAHPM steering group used existing publications to define 9 domains of PC in oncology: Symptom Assessment and Management (A&amp;M), Psychosocial A&amp;M, Spiritual and Cultural A&amp;M, Communication and Shared Decision-Making, Care Planning, Appropriate Palliative Care and Hospice Referral, Coordination and Continuity of Care, Carer Support, and End-of-Life Care. Within each domain, key PC activities were itemized and described (e.g. pain assessment using a standardized scale at every clinical encounter), totaling 966 activities. A 31-member multidisciplinary panel participated in a modified RAND Delphi process, rating each activity on a 9-point scale according to 3 constructs: importance, feasibility, and scope of practice. Composite scoring categorized activities as either reasonably within scope of oncology practice, uncertain, or typically not in scope. Results: The response rate for each round was 94%. Notable panelist concerns included the breadth of palliative care practice, the varied access that oncology practices have to PC resources, and the varied individual knowledge and comfort with specific activities. Despite multiple small ranking changes between surveys, only 41 activities changed in scope of practice category. Of 966 activities, 62% were ranked as reasonably within scope of oncology practice, 36% were uncertain, and 2% were typically not in scope. Conclusions: Despite the diverse range of PC activities, panelists strongly agreed that more than half were reasonably within the scope of adult medical oncology practice. These items provide a foundation for improving palliative care delivery within an oncology practice, with suggestions for future performance measures and quality improvement activities.

Five Things Physicians and Patients Should Question in Hospice and Palliative Medicine

Overuse or misuse of tests and treatments exposes patients to potential harm. The American Board of Internal Medicine Foundation's Choosing Wisely® campaign is a multiyear effort to encourage physician leadership in reducing harmful or inappropriate resource utilization. Via the campaign, medical societies are asked to identify five tests or procedures commonly used in their field, the routine use of which in specific clinical scenarios should be questioned by both physicians and patients based on the evidence that the test or procedure is ineffective or even harmful. The American Academy of Hospice and Palliative Medicine (AAHPM) was invited, and it agreed to participate in the campaign. The AAHPM Choosing Wisely Task Force, with input from the AAHPM membership, developed the following five recommendations: 1) Don't recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral-assisted feeding; 2) Don't delay palliative care for a patient with serious illness who has physical, psychological, social, or spiritual distress because they are pursuing disease-directed treatment; 3) Don't leave an implantable cardioverter-defibrillator activated when it is inconsistent with the patient/family goals of care; 4) Don't recommend more than a single fraction of palliative radiation for an uncomplicated painful bone metastasis; and 5) Don't use topical lorazepam (Ativan®), diphenhydramine (Benadryl®), and haloperidol (Haldol®) (ABH) gel for nausea. These recommendations and their supporting rationale should be considered by physicians, patients, and their caregivers as they collaborate in choosing those treatments that do the most good and avoid the most harm for those living with serious illness.

Estimate of Current Hospice and Palliative Medicine Physician Workforce Shortage

In the context of the establishment of a new medical specialty, rapid growth in hospices and palliative care programs, and many anecdotal reports about long delays in filling open positions for hospice and palliative medicine (HPM) physicians, the American Academy of Hospice and Palliative Medicine (AAHPM) appointed a Workforce Task Force in 2008 to assess whether a physician shortage existed and to develop an estimate of the optimal number of HPM physicians needed. Develop estimates of the current supply and current need for HPM physicians. Determine whether a shortage exists and estimate size of shortage in full-time equivalents (FTEs) and individual physicians needed. The Task Force projected national demand for physicians in hospice- and in hospital-based palliative care by modeling hypothetical national demand on the observed pattern of physician use at selected exemplar institutions. The model was based on assumptions that all hospices and hospitals would provide an appropriate medical staffing level, which may not currently be the case. Approximately 4400 physicians are currently HPM physicians, as defined by board certification or membership in the AAHPM. Most practice HPM part time, leading to an estimated physician workforce level from 1700 FTEs to 3300 FTEs. An estimated 4487 hospice and 10,810 palliative care physician FTEs are needed to staff the current number of hospice- and hospital-based palliative care programs at appropriate levels. The estimated gap between the current supply and the hypothetical demand to reach mature physician staffing levels is thus 2787 FTEs to 7510 FTEs, which is equivalent to 6000-18,000 individual physicians, depending on what proportion of time each physician devotes to HPM practice. An acute shortage of HPM physicians exists. The current capacity of fellowship programs is insufficient to fill the shortage. Changes in graduate medical education funding and structures are needed to foster the capacity to train sufficient numbers of HPM physicians.

Position Statement on Physician-Assisted Death

In the past year, the American Academy of Hospice and Palliative Medicine (AAHPM) Board of Directors charged the Academy's Ethics Committee with updating our positions on a number of topics, and the board recently approved and published position statements on artificial hydration and nutrition, palliative sedation, and physician-assisted death, as well as statements on palliative care research, quality palliative care, and palliative care accreditation.AAHPM supports intense efforts to alleviate suffering and to reduce any perceived need for physician assisted death (PAD). The Board of Directors respects the beliefs and opinions of all members and does not suggest that physicians or healthcare providers be forced to deliver care they see as harmful or wrong. We want all patients to continue to receive the best possible palliative care, whatever decisions are made regarding PAD.Situations in which patients or their surrogates request physician assisted death (PAD) are particularly challenging for physicians and other healthcare providers because they raise significant clinical, ethical, and legal issues. Deep disagreement persists about the morality of PAD, and sincere, compassionate, and morally conscientious individuals stand on both sides of this debate.Rather than take a position of one side or the other, the Board's position of “studied neutrality” is intended to stimulate thinking and discussion about how best to respond to the urgent needs of the few dying patients who continue to suffer despite expert palliative care.

National Survey of Perspectives of Palliative Radiation Therapy: Role, Barriers, and Needs

Despite growth of palliative care programs and evidence on the effectiveness of radiotherapy in palliating cancer symptoms, radiotherapy is probably underused in this setting. Radiation and medical oncologists and palliative medicine specialists were surveyed regarding the perceived role of palliative radiotherapy and barriers to its use. The survey was sent electronically to all physician members of the American Society for Therapeutic Radiology and Oncology (ASTRO) and the American Academy of Hospice and Palliative Medicine (AAHPM) and a random sample of American Society of Clinical Oncology (ASCO) members, with known e-mail addresses. Response rates were 27%, 14% and 26% for ASTRO, ASCO, and AAHPM respondents, respectively. Although most felt radiotherapy is an effective and important option for palliation of some common cancer symptoms, referrals for such therapy may be declining. Most agreed that radiation oncologists should be more involved in palliative care; however, multiple barriers were identified, such as poor reimbursement, emotional burden of care, insufficient training/knowledge, and the sense of unwillingness of others to share delivery of such services. Although multiple barriers limit optimal integration, most agree that there should be greater national and professional society efforts to promote the advancement of radiation oncology in the area of palliative care.

Position Statement on Physician-Assisted Death

In the past year, the American Academy of Hospice and Palliative Medicine (AAHPM) Board of Directors charged the Academy's Ethics Committee with updating our positions on a number of topics, and the board recently approved and published position statements on artificial hydration and nutrition, palliative sedation, and physician-assisted death, as well as statements on palliative care research, quality palliative care, and palliative care accreditation.AAHPM supports intense efforts to alleviate suffering and to reduce any perceived need for physician assisted death (PAD). The Board of Directors respects the beliefs and opinions of all members and does not suggest that physicians or healthcare providers be forced to deliver care they see as harmful or wrong. We want all patients to continue to receive the best possible palliative care, whatever decisions are made regarding PAD.Situations in which patients or their surrogates request physician assisted death (PAD) are particularly challenging for physicians and other healthcare providers because they raise significant clinical, ethical, and legal issues. Deep disagreement persists about the morality of PAD, and sincere, compassionate, and morally conscientious individuals stand on both sides of this debate.Rather than take a position of one side or the other, the Board's position of “studied neutrality” is intended to stimulate thinking and discussion about how best to respond to the urgent needs of the few dying patients who continue to suffer despite expert palliative care.

A Needs Assessment: Fellowship Directors Forum of the American Academy of Hospice and Palliative Medicine

The Fellowship Directors Forum, a special interest group of the American Academy of Hospice and Palliative Medicine (AAHPM) initiated an assessment of the needs of directors of fellowship programs in the emerging specialty of hospice and palliative care. One major finding, which may contribute to understanding the needs of other new disciplines, is that directors come into this role with clinical and teaching experience, but lacking administrative, educational, and management skills perceived as necessary to success. A study team collected data from current and former fellowship directors across the United States using an online survey and telephone interviews. The survey was sent to 60 current and former directors, with a 60% response rate, and 16 randomly selected directors were interviewed. Results showed that directors believe development of an outcome-based standardized curriculum is vitally important to advancement of the field, and that this should be developed collaboratively through the Forum. Although directors were confident of their own clinical and teaching skills, directors identified a lack of adequate training and experience in several management and educational skill areas critical to running a successful fellowship program. The study team made several recommendations: develop models from parts of existing programs that can be incorporated into a standardized curriculum to meet Accreditation Council of Graduate Medical Education (ACGME) requirements; provide workshops and toolkits for new directors to address the lack of management and educational skills; and establish new communication methods through more or longer forum meetings, a dedicated website, and an online discussion group.

Initial voluntary program standards for fellowship training in palliative medicine.

Initial voluntary standards for fellowship programs in palliative medicine were developed through a collaborative process involving the directors of fellowship training programs, the American Academy of Hospice and Palliative Medicine (AAHPM), and the American Board of Hospice and Palliative Medicine (ABHPM). These groups worked with a consultant and representatives from the American Board of Medical Specialties (ABMS) and the Accreditation Council for Graduate Medical Education (ACGME) to create a training structure for the programs that will maximize the likelihood for recognition and accreditation of the subspecialty. An accreditation group modeled after an ACGME residency review committee will be formed to review and adopt the standards, then accredit programs voluntarily.

On the 10th anniversary of the organization of the American Academy of Hospice and Palliative Medicine (AAHPM): The first 10 years

The American Academy of Hospice and Palliative Medicine (originally chartered as the Academy of Hospice Physicians in 1988) is an organization of physicians devoted to advancing hospice and palliative medicine in the United States. The academy's mission is "physicians dedicated to promoting quality hospice care for the terminally ill through medical education, research, and training." The academy obtained specialty recognition from the AMA in 1996 and became the first physicians' group to publish its position on physician-assisted suicide in 1991 and again in 1997.