What is case management in palliative care? An expert panel study

Pharmacist Interventions in a Palliative PLUS Program at a Veterans Affairs Medical Center

Background: Palliative PLUS (PP) at the Minneapolis Veterans Affairs Health Care System (MVAHCS) is an interdisciplinary team that seeks to improve veteran access to palliative and hospice resources. Palliative care pharmacists were incorporated to increase patient access to palliative specialties. Objective: To identify and categorize pharmacist interventions within an outpatient PP team at the MVAHCS. Methods: This quality improvement project was a retrospective analysis of the electronic health record. Results: A total of 84 patients were participating in the PP program over 13 months. Among those patients, 25 had pharmacist involvement and a total of 56 interventions were identified. Of those interventions, 29 (51.8%) were direct interventions and 27 (48.2%) were curbside consults. Most interventions involved medication counseling and medication adherence. Conclusion: Pharmacists made an impact on the PP team through direct patient interventions involving medication counseling and aided the interdisciplinary team by facilitating patient medication adherence.

Qualitative evaluation of a palliative care case management intervention for patients with incurable gastrointestinal cancer (PalMaGiC) in a hospital department

PURPOSE

Generalist palliative care in hospital departments largely lacks an overall structure to fully manage the symptom burden and support needs of patients with incurable gastrointestinal cancer. Palliative care case management interventions show promising results in reducing healthcare use and enhancing quality of life. Less is known about these interventions and their potential to improve the quality of generalist palliative care in hospital departments. The aim of this study was to explore patients' experience of a palliative care case management intervention (PalMaGiC) to acquire knowledge about its advantages and disadvantages and, if needed, adjust the intervention.

METHODS

Qualitative semi-structured interviews with patients (n = 14) with incurable gastrointestinal cancers of the oesophagus, pancreas, colon, or rectum were conducted and analysed using content analysis. Participants in the study were affiliated with PalMaGiC, an intervention in a gastroenterology department based on symptom assessment, care planning, care coordination, and needs-based follow-up.

RESULTS

Participants perceived the intervention as filling a gap and as a secure lifeline in the healthcare system since it provided 24-h access, a designated specialist nurse, and a patient-healthcare alliance. Using a needs-based approach, PalMaGiC changed the participants' focus from disease to quality of life. Participants requested more open dialog within complementary and alternative medicine, greater focus on promoting hope and using need assessment questionnaires differently in assessing symptoms and problems.

CONCLUSION

The PalMaGiC intervention can potentially meet the needs of patients requiring palliative care in hospital departments, but further development of the content and personalised approach is needed.

Organizational determinants of information transfer in palliative care teams: A structural equation modeling approach

Several organizational factors facilitate or hinder information transfer in palliative care teams. According to past research, organizational factors that reduce information transfer include the inconsistent use of shared electronic patient files, frequent changes of healthcare staff, a lack of opportunities for personal exchange, and a lack of evaluation of collaborative processes. Insufficient information sharing between professionals can negatively impact patient safety, whereas studies have shown that some organizational factors improve collaboration between professionals and thus contribute to improved patient outcomes. The main purpose of this study is thus to investigate whether, and if so how, organizational factors contribute to successful information exchange in palliative care teams in Switzerland, while also accounting for the different care contexts of primary and specialized palliative care. A nationwide survey was aimed at medical professionals working in palliative care. In total, 379 participants (mean age = 49.8 years, SD = 10.3) were included in this study. Two main outcome variables were examined: healthcare providers' satisfaction with information transfer in their team and their overall satisfaction with communication in their team. Hypotheses were tested by employing structural equation modeling. Findings revealed that the strongest predictors for effective information transfer in palliative care teams were sufficient opportunities for face-to-face meetings and supervision alongside feedback tools to improve collaborative practices and the application of guidelines and standards for collaboration. Face-to-face meetings were an even greater contributor to information transfer in specialized settings, whereas sharing the same work-based values with colleagues was considered more important in primary settings. Results from this study contribute to the existing literature elucidating how information transfer is facilitated in the field of palliative care. If proposed measures are implemented, this could possibly improve patient outcomes in palliative care. Furthermore, the findings can be useful for healthcare organizations and associations to make more efficient resource allocation decisions with the aim to optimize information transfer within the workforce.

Experiences of Dutch general practitioners and district nurses with involving care services and facilities in palliative care: a mixed methods study

Background

Generals practitioners (GPs) and district nurses (DNs) play a leading role in providing palliative care at home. Many services and facilities are available to support them in providing this complex care. This study aimed to examine the extent to which GPs and DNs involve these services, what their experiences are, and how involvement of these services and facilities can be improved.

Methods

Sequential mixed methods consisting of an online questionnaire with structured and open questions completed by 108 GPs and 258 DNs, followed by three homogenous online focus groups with 8 GPs and 19 DNs, analyzed through open coding.

Results

Most GPs reported that they sometimes or often involved palliative home care teams (99%), hospices (94%), and palliative care consultation services (93%). Most DNs reported sometimes or often involving volunteers (90%), hospices (88%), and spiritual caregivers (80%). The least involved services and facilities were psychologists and psychiatrists (51% and 50%) and social welfare (44% and 57%). Main reason for not involving services and facilities was ‘not needing’ them. If they had used them, most GPs and DNs (68–93%) reported solely positive experiences. Hardly anyone (0–3%) reported solely negative experiences with any of the services and the facilities. GPs and DNs suggested improvements in three areas: (1) establishment of local centers giving information on available services and facilities, (2) presentation of services and facilities in local multidisciplinary meetings, and (3) support organizations to proactively offer their facilities and services.

Conclusion

Psychological, social, and spiritual services are involved less often, suggesting that the classic care model, which focuses strongly on somatic issues, is still well entrenched. More familiarity with services that can provide additional care in these areas, regarding their availability and their added value, could improve the quality of life for patients and relatives at the end of life.

Analysing the impact of a case management model on the specialised palliative care multi-professional team

PURPOSE

Palliative care (PC) involves many health care providers leading to a high complexity of structures that requires efficient coordination as provided by case management (CM). Our study aimed to evaluate the effects of CM newly implemented in a specialised palliative care unit by evaluating team members' tasks and time resources before (T0) and after implementation (T1). It was hypothesised that team members would be able to spend less time on organisational and administrative tasks and more time on patient care.

METHODS

A prospective pre-post study design was used. Time distribution of different tasks at T0 and T1 was compared between three different professional groups: physicians, nursing staff and social work. To document their tasks and time required, a documentation form with several items for each profession was developed. Data was analysed using t tests for independent samples.

RESULTS

After Bonferroni correction, a significant pre-post difference was found for the time spent on "discharge interview and discharge" as rated by the physicians (p < .001) with less time spent on this activity after CM implementation. The nursing staff had significantly more time for "conversations with patients" (p < .001) after CM implementation. Moreover, they spent significantly less time on "patient-related requests/advice by telephone" (p < .001) and "discussions with relatives/participation in family discussions" at post-assessment (p < .001). The social worker had significantly more time for "patient advice and support services" (p = .013) after CM implementation.

CONCLUSIONS

Integrating CM can be time efficient and ensures team members to spend more time on their core tasks in patient care.

Aspects and Intensity of Pediatric Palliative Case Management Provided by a Hospital-Based Case Management Team: A Comparative Study Between Children With Malignant and Nonmalignant Disease

OBJECTIVES

Anticipating case management is considered crucial in pediatric palliative care. In 2012, our children's university hospital initiated a specialized pediatric palliative care team (PPCT) to deliver inbound and outbound case management for children with life-shortening disease. The aim of this report is to gain insight in the first 9 months of this PPCT.

METHODS

Aspects of care during the first 9 months of the PPCT are presented, and comparison is made between patients with malignant disease (MD) and nonmalignant disease (NMD) in a retrospective study design. Insight in the aspects of care of all patients with a life-shortening disease was retrieved from web-based files and the hour registrations from the PPCT.

RESULTS

Forty-three children were supported by the PPCT during the first 9 months: 22 with MD with a median of 50 (1-267) days and 29 minutes (4-615) of case management per patient per day and 21 patients with NMD with a median of 79.5 (5-211) days and 16 minutes of case management per day (6-64). Our data show significantly more interprofessional contacts for patients with MD and more in-hospital contacts for patients with NMD. The median number of admission days per patient was 11 (0-22) for MD (44% for anticancer therapy) and 44 (0-303) for NMD (36% for infectious diseases).

SIGNIFICANCE OF RESULTS

This overview of aspects of pediatric palliative case management shows shorter but more intensive case management for MD in comparison with NMD. This insight in palliative case management guides the design of a PPCT.

A prospective study on the characteristics and subjects of pediatric palliative care case management provided by a hospital based palliative care team

Background

Case management is a subject of interest within pediatric palliative care. Detailed descriptions of the content of this type of case management are lacking. We aim to describe the contents of care provided, utilization of different disciplines, and times of usage of a pediatric palliative care case management program compared for patients with malignant disease (MD) and non-malignant disease (NMD).

Methods

A three-month prospective study, with questionnaires filled in by members of a pediatric palliative care team (PPCT) for each contact with parents.

Results

Four hundred fifty-five contacts took place with parents of 70 patients (27MD, 43NMD). Sixty-two percent of all contacts were with the specialized nurse. The child life specialists, psychologist and social worker were also regularly consulted, the chaplain was not consulted. Ninety-five percent of all contacts took place between 8 am and 6 pm during weekdays, a limited number between 6 pm and 9 pm. Twenty-five percent of all contacts were proactively initiated by the PPCT, 25 % were initiated by parents. In these care characteristics, no differences were seen for MD and NMD patients. Psychosocial topics were addressed most frequently. MD patients consulted the PPCT more often about school and NMD patients about socio-economic issues.

Conclusions

All different disciplines of the PPCT were regularly consulted, except for the chaplain. With an easy accessible team with a highly pro-active approach, availability from 8 am to 9 pm seems sufficient to accommodate patient’s and parent’s needs. More anticipation seems required for socio-economic topics. This insight in pediatric palliative case management can provide guidance in the development of a new PPCT.

Case management in primary palliative care is associated more strongly with organisational than with patient characteristics: results from a cross-sectional prospective study

BACKGROUND

Case managers have been introduced in Dutch primary palliative care; these are nurses with expertise in palliative care who offer support to patients and informal carers in addition to the care provided by the general practitioner and home care nurses. This study aims to describe support and investigate what characteristics of patients and the organizational setting are related to the number of contacts and to the number of times topics are discussed between the case manager and patients and/or informal carers.

METHODS

Prospective study following cancer patients (n = 662) receiving support from a palliative care case manager in Dutch primary care, using registration forms filled out by the case manager after contact with the patient and/or informal carer. In backward linear regression, the association was studied between patient or organizational characteristics and the number of contacts and the number of times conversation topics were discussed.

RESULTS

Organizational characteristics add more to explained variability in data than patient characteristics. Case managers provide support in a flexible manner with regard to the number, mode, persons present, and duration of contacts. Support covered all domains of palliative care, with most attention given to physical complaints, life expectancy and psychological aspects.

CONCLUSIONS

Support offered by the case managers is prompted by characteristics of the organization for which they work. This is contradictory to the idea of patient centered care highly valued in palliative care.

Application of integrative information system improves the quality and effectiveness of cancer case management

Cancer case management provides consecutive care during the entire process through diagnosis to treatment and follow-up. We established an integrative information system with integration of the health information system. This integrative information system shortened the time spent on case screening, follow-up data management, and monthly data summarization of case managers. It also promoted the case follow-up rate. This integrative information system may improve the quality and effectiveness for cancer case management, one important part of cancer nursing.

Palliative care case managers in primary care: a descriptive study of referrals in relation to treatment aims

BACKGROUND

Three important elements of the World Health Organization (WHO) definition of palliative care are: 1) it includes patients who may have cure or life prolongation as treatment aims besides palliative care; 2) it is not exclusively for cancer patients; and 3) it includes attention to the medical, psychological, social, and spiritual needs of the patients and their families. Case managers (nurses with expertise in palliative care) may assist generalist primary care providers in delivery of good palliative care.

OBJECTIVES

This study investigates the referral of patients to case managers in primary care with regard to the three elements mentioned: diagnosis, treatment aims, and needs as reflected in reasons given for referral.

METHODS

In this cross-sectional survey in primary care among case managers and referrers to case management, case managers completed questionnaires for 687 patients; referrers completed 448 (65%).

RESULTS

Most patients referred have a combination of treatment aims (69%). Life expectancy and functional status of patients are lower for those with a treatment aim of palliation. Almost all (96%) of those referred are cancer patients. A need for psychosocial support is frequently given as a reason for referral (66%) regardless of treatment aim.

CONCLUSIONS

Referrals to case managers reflect two of three elements of the WHO definition. Mainly, patients are referred for support complementary to medical care, and relatively early in their disease trajectory. However, most of those referred are cancer patients. Thus, to fully reflect the definition, broadening the scope to reach other patient groups is important.

Association between palliative case management and utilization of inpatient, intensive care unit, emergency department, and hospice in Medicaid beneficiaries

Association between palliative case management (PCM) and the utilization of major health services during the last 30 days of life in Medicaid patients with cancer was assessed using retrospective cohort analysis. There were 132 PCM enrollees in the intervention group and 54 non-PCM enrollees in the comparison group. The intervention group had lower inpatient admission rate than that of the comparison group (56.8% vs 74.1%), lower ICU admission rate (12.9% vs 24.1%), longer mean hospice days (45.8 vs 31.1 days), and lower percentage of persons with death in hospital (24.2% vs 35.9%). No statistically significant differences were found in mean intensive care unit days (8.7 vs 9.7 days), treat-and-release emergency department visit rate (22.0% vs 16.7%), or hospice election rate (65.9% vs 70.4%). Palliative case management may reduce hospitalization and increase hospice use in patients nearing death.

Effectiveness of nurse case management compared with usual care in cancer patients at a single medical center in Taiwan: a quasi-experimental study

Background

In order to improve treatment and care quality for cancer patients, nurse case management model has applied generally in the clinical practice. However there were only few evidence-based studies on the relative benefits in Taiwan. Further analysis and feedback application are needed. The aim of this study is to evaluate the effectiveness of care quality in cancer patients with nurse case management.

Methods

This study was conducted with a quasi-experimental design in a national medical center in Northern Taiwan. Patients diagnosed as lung, liver, breast, colon, buccal or cervical cancers were eligible for inclusion. A total number of 600 subjects randomly selected from the cancer case management system enrolled in the case managed group, and 600 patients who received usual care were randomly selected from cancer registry and enrolled in the control group. The study instrument was developed to measure care effectiveness, including the rates of patient continuing treatment, non-adherence to treatment, prolonged hospitalization, unplanned readmission, and planned admission for active treatment. The content validity of expert was assessed as 0.9.

Results

The nurse case management significantly decreased the unplanned readmission rate caused by infection (1.5% vs. 4.7% in the control group, p = 0.002). The rate of patient continuing treatment in the institution significantly increased in the case managed group (93.8% vs. 84.8% in the control group, p < 0.001). The planned admission rates in 14 days and in 15–30 days for active treatment also significantly increased in the case managed group (18.4.% vs. 3.9% in the control group and 34.5% vs. 10.4% in the control group, respectively, p < 0.001). The results indicated that nurse case management provided better control in timeliness and continuity of patient treatment.

Conclusions

This study demonstrated that cancer case management could improve the effectiveness of cancer care services and concretely illustrated a comprehensive model for oncology patients in Taiwan. In addition, the model could be optimized for further application and improvement of cancer care. Future investigations are needed to develop precise and rigorous evaluation to optimize the utilization of cancer case management.

Palliative care case management in primary care settings: a nationwide survey

BACKGROUND

In case management an individual or small team is responsible for navigating the patient through complex care. Characteristics of case management within and throughout different target groups and settings vary widely. Case management is relatively new in palliative care. Insight into the content of care and organisational characteristics of case management in palliative care is needed.

OBJECTIVES

To investigate how many case management initiatives for palliative care there are in the Netherlands for patients living at home; to describe the characteristics of these initiatives with regard to content and organisation of care.

SETTING

Primary care.

DESIGN AND PARTICIPANTS

A nationwide survey of all 50 coordinators of networks in palliative care in the Netherlands was conducted. Additional respondents were found through snowball sampling. We looked at 33 possible initiatives using interviews (n=33) and questionnaires (n=30).

RESULTS

We identified 20 initiatives for case management. All stated that case management is supplemental to other care. In all initiatives the case managers are registered nurses and most possess higher vocational education and/or further training. All initiatives seek to identify the multidimensional care needs of the patients and the relatives and friends who care for them. Almost all provide information and support and refer patients who need care. Differences are found between the organisations offering the case management, their target groups, the names of the initiatives and whether direct patient care is provided by the case manager.

CONCLUSIONS

In the Netherlands, case management in palliative care is new. Several models of delivery were identified. Research is needed to gain insight into the best way to deliver case management. By describing characteristics of case management in palliative care, an important first step is made in identifying effective elements of case management.