How to Start an Outpatient Palliative Care Program

Sharon Tapper, MD

About 5 years ago, it became clear to me that patients seen by our Palliative Care Service in the acute hospital (1) needed follow-up when they were discharged, (2) many would not have wanted to be there in the first place, and (3) most did not have their wishes documented in an actionable format prior to admission.

I am part of a multi-specialty physician group without a Palliative Care Department. So, how do you start a program from “scratch”? What I did was visualize the utopia I wanted to create… a system of care delivery that puts the patient/person/family at the center of care and a mobile multidisciplinary team follows that patient in the last year of life — regardless of the physical location of the patient. This includes visits to home, nursing home, LTAC, office, hospital, etc. The pillars of care are symptom management, advance care planning, including attention to documentation of goals of care and POLST.

To start, I created a PowerPoint presentation with my “ask.” This included a definition of palliative care, slides with studies demonstrating the proven benefits known in the hospital/outpatient setting of cost savings, symptom management, etc. I also created an “old paradigm” (i.e., the current patient experience) and the “new paradigm” — how that patient’s experience would change with the creation of the new service. I did a cursory calculation of financial needs based on how much the physician/NP would bring in with work RVUs and how much the program would cost to run. It was mostly labor overhead as we utilized clinic space already built. This helped to define the financial contribution needed to fund the program.

I got leadership buy-in for the program with the PowerPoint. This is one of the keys to success. The other is getting physician buy-in. They are your referral source. I did this by having physicians involved with the planning of the program. Once the program was in the pilot phase, I developed another presentation specifically directed to the physicians. I went to all primary care and select specialty meetings to describe the program, how to refer, etc. This was before the first patient was enrolled. Other stakeholders are the local hospices, home health agencies, hospitals and nursing homes.

Well, we have been up and running for 2 years. We have seen over 1,000 patient/persons/families and will have completed the rollout to our 900,000 patient base by the first quarter of 2014.

Have you started a new program at your institution? How did you generate support for the idea? Were there pitfalls you didn’t expect? I hope that sharing the lessons we’ve learned along the way will help guide our colleagues starting out on this road and lead to better care for more patients.

Dr. Tapper serves as Medical Director of the Palo Alto Medical Foundation’s Outpatient Palliative Care and Support Services. This post previews the latest installment of AAHPM’s Hospice and Palliative Medicine Profiles in Innovation.