PALLIATIVE CARE IN THE ED – A WISE CHOICE

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You have probably heard the term “palliative medicine” a lot lately. At least I hope you have! But what does this type of medicine have to do with the Emergency Department?

Let’s start with some basic questions…How often do you ask yourself :

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  • Why am I doing this tube/line/CPR/futile procedure on the poor person who will not get any benefit, and most likely get worse?”
  • How many patients do you see per week that you do a full work-up and management that you would NOT be surprised if they died within the next 6 months?
  • How often are you coding a patient that has obviously been declining for a while with a chronic/terminal condition such as CHF/COPD/dementia and the family has no conception of what is happening?

If you identify with any of these scenarios then read on…

Just as many serious public health questions have ended up on our doorstep (violence, the uninsured, addiction, HIV,  and chronic pain) managing terminal illness has become our problem as well. A large group of patients and families really need help, and they are not getting it anywhere else.

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ACEP chose initiating palliative care as one of our five contributions to The Choosing Wisely Campaign in response to these concerns. But how do we make this operational? Where can we start? The field of Palliative Medicine is huge but emergency physicians can have a big impact!

We have a big impact because what  we do in the ED becomes, for better or worse, the treatment track upon admission. It is essential that we initiate treatment in-line with a patient’s goals.   With a bit of training we ED docs can become great at helping patients voice their goals and in turn become leaders for other specialties.

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We must shift our focus from “getting the DNR” to getting the patient’s “goals of care”. In order to do this well, we must get away from dichotomous questions like “do you want us to do everything? or nothing?”  We must get a sense of the patient and their family. A very useful order of questions is as follows:

  1. What is your understanding of your illness?
  2. How much information do you want to be told?
  3. If your health situation worsens, what are your most important goals?
  4. What are your biggest fears and worries about the future?
  5.  What are you willing to trade off for more time?

hopeIf you get stuck, a great statement is the “I hope” statement. “Of course we hope that you will continue to improve, but as we hope for the best we also need to prepare for the worst.”  The ideal is to synthesize the medical science with the patient’s goals, THEN make recommendations.

These patients and their families come to the ED with acute symptoms due to a crisis point in the trajectory of their illness. We need to become experts at palliative symptom management (have you ever considered Haldol for intractable vomiting?). If we can make people comfortable, we have a shot at having meaningful discussions with them and their families about the next steps.

Often I find that talking about symptoms – starting with pain, nausea, vomiting, then getting into deeper issues (fears and anxieties, depression, appetite, weight loss) restores hope in patients and families. This helps build trust when you make recommendations for treatment and disposition.

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An important tool that has been legally and officially adopted in the State of NJ is the POLST Form. These Forms are transferable and legally binding across all health care settings (as opposed to DNRs). While generally meant to be filled out by the patient and his/her primary care provider, any physician can help a patient enact one.

Obviously there is still much work to be done outside of emergency medicine to create the programs and systems needed to properly care for people at the end of their lives. However, we see these patient’s everyday and can be the ones that:  

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  • Identify these patients
  • Assist the patient and family in clarifying their goals
  • Modify the immediate treatment plan based on those goals
  • Facilitate a hand-off to a more comprehensive services:
    • Private medical doctors
    • Palliative Care services
    • Hospice (inpatient and outpatient)

If you are interested in learning more about palliative medicine please visit us at: ACEP Palliative Medicine Section and consider joining!

KATE PICKate Aberger MD is board certified in Emergency Medicine and Hospice and Palliative Medicine. She practices at St. Joseph’s Regional Medical Center in Paterson and is the incoming President of ACEP’s Palliative Medicine Section.

20 Things Changing EM: THE SILVER TSUNAMI

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This is part of a continuing series exploring the Confusing array of changes to healthcare and identify the Opportunities for our specialty. The goal is to give you three things:

  • The What
  • The Why
  • The Opportunity (for our emergency medicine)

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There is a tidal wave that is coming. The baby boomer generation (those born 1946-1964) are now entering retirement age. Combined with increases in life expectancy it is causing an unprecedented  “graying” of the United States and most other industrialized countries. Just look at the last census. While the total population only increased by 9.7% those over 62 increased by 21%!  

In the State of New Jersey those over 65 with increase from 1.2 Million now to almost 2 Million by 2030.

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So how will this impact the ED? Based on CMS data geriatric patients utilize emergency department services at a rate 7 times that of the rest of the population and generally make up 15-20% of ED volume. They account for over 40% of all admissions and nearly half of ICU admissions. While in the hospital their LOS tends to be 1-2 days longer on average. Furthermore these patients are living longer and staying independent despite increasingly complex web of chronic conditions.

As this Tsunami is crashing onto our healthcare shores other trends will be eroding the traditional care pillars. First the pool of primary care providers is graying as well and replacements are not anticipated to keep up with demand. Second despite rising demand EDs are closing along with the hospitals they are based in. Third more healthcare is expected to be provided outside the hospital setting.

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So now we know we have a rapidly growing population of very complex patients to look forward to. So what should emergency medicine do? Where is our opportunity to improve care?

We in emergency medicine are in the right place and have many of the tools that this population needs. We are already experts in evaluation of acute conditions (which many of these patients will have); we have spent decades honing our system responses to critical patients (which many of these patients will be); and we are the masters of collaboration (which these patients will really need).

photoIt is in that last category that we can show the value of our care. Elderly patients and the desire to keep those with chronic, complex conditions at home will need considerable coordination of care at times of acute illness or decompensation. We are positioned to be the hub of that care by providing:

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  • Coordination of hospital resources
  • Coordination of community resources
  • Services such as extended observation (in and out of the hospital)
  • Palliative care

Because of our unique position and availability emergency medicine has always excelled at related tasks (observation medicine, hyperbarics, travel medicine, urgent care). While more service intensive we have the same opportunity for geriatrics. Some of these could include:

  • Comprehensive Geriatric Screening
  • Emergent/Urgent at-home evaluations through community paramedicine
  • Telemedicine for urgent evaluations of nursing home patients
  • Palliative medicine

4th-Lifeguard-StandTo finish up the Silver Tsunami analogy. We are the life guards on the health care beach. Our tasks will continue to be the care of the acute conditions and when possible the prevention of illness decompensation.

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Written by:

Mark Rosenberg DO, MBA, FACEP, FACOEP-D

Mark Rosenberg PictureDr. Rosenberg is the Chairman of Emergency Medicine, Chief Geriatric Emergency Medicine, and Palliative Medicine at St. Joseph’s Regional Medical Center in Paterson, NJ. He is the Secretary/Treasurer of NJ-ACEP, and a member of  the Presidents Council for ACEP as well as the Council Steering Committee.   He can be reached at 973-754-2240 or mark.emergency@gmail.com. 

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This publication represents the personal opinion of the author and does not reflect the official policy of NJ-ACEP or the American College of Emergency Physicians. You can contact us here.

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20 Things Changing EM: ACCOUNTABLE CARE ORGANIZATIONS

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As explained on the Intro page this is the first in a series that seeks to explore many of the “things” that are (or could) affect the future of emergency medicine. It is part of NJ-ACEPs year-long commitment to exploring the Confusing array of changes to healthcare and identify the Opportunities for our specialty. The goal is to give you three things:

  • The What
  • The Why
  • The Opportunity (for our specialty)

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ACCOUNTABLE CARE ORGANIZATIONS

According to the CMS website: Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients. The goal of an ACO is to:

  • ensure that patients, especially the chronically ill, get the right care at the right time
  • avoid unnecessary duplication of services and preventing medical errors
  • deliver high-quality care and spending health care dollars more wisely
  • share in the savings it achieves for the Medicare program.

The essential component of this model is the transfer of financial risk AND responsibility for quality from the 3rd party entity (in this case medicare) to a “provider-led” organization. In some ways it is similar to the 1970s concept of Health Maintenance Organizations except that quality of care is supposed to be as important as cost reduction.

The financial incentive for an ACO is a substantial share of calculated savings in the care of medicare patients through better coordinated and (hoped for) reduced care. However in some cases the ACOs could also be liable for calculated increases in the cost of care provided. Currently there are also “33 quality reporting metrics” for physicians that effect payment under the Shared Savings Program.

Because of the size of beneficiaries required (> 5000 enrollees) and the complex network needed to provide care most ACOs have formed from large, already existing entities. In NJ many are based around hospital-centered health networks though others have formed as well. Currently there are 10 ACOs approved by CMS in our State:

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  • Advocare Wallgreens Well Network
  • Atlantic Health System ACO
  • Atlanticare Health Solutions
  • Barnabas Health ACO – North
  • Central Jersey ACO
  • Hackensack Physician-Hospital Alliance
  • HNMC Hospital\Physician (Holy Name)
  • Meridian Accountable Care Organization
  • Optimus Healthcare Partners
  • Summit Health- Virtua

ACOs and EMERGENCY MEDICINE

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As with so many things that will be written about in this series the future of ACOs and its impact on emergency medicine is unknown. Some emergency physicians (particularly those employed by hospitals) are already members of an ACO. Others may end up joining through their group practices or provide services to ACOs through other contracted relationships.

There are more questions than answers currently:

  • How will the ACOs goals of reducing the cost of care interact with our responsibilities under EMTALA and Prudent Layperson?
  • How would a group of emergency physicians negotiate fair payment based upon the incentives ACOs have?
  • And most importantly how do we show our value?

The opportunity I believe lies in that last question. We provide value now. We cost Just 2% of  all US healthcare dollars. We provide acute care, safety-net care, and already straddle the link between hospital-based and out-patient care. We coordinate care for many of those same patients already.

But we need to better define that value and show that a trip to the ED is not an expense to be reduced but an important episode of care that can reduce other costs. Because this is a medicare program the patients involved are almost entirely elderly or disabled. Most of these patients present with either acute disease states complicated by chronic conditions or exacerbations of their chronic medical conditions.

So what value can we add beyond the acute episode of care?  Clearly improving communication and coordination with their primary providers (most will have more than one) will be key. Others have also talked about the ED expanding its role as a hub that directs patients to the various spokes where the rest of their care is provided.

Emergency physicians will not be able to carry this burden solely. It will create the need for more care navigators (usually nurses or APNs) to couple our What (the patient needs) with knowledge of Where and How (it can be provided).

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Written by:

tib-adinarod-6087-200David Adinaro MD, FACEP

Dr. Adinaro is the president of NJ-ACEP for 2013-14 and is the Chief of the Adult Emergency Department at St. Joseph’s Regional Medical Center in Paterson, NJ. He is also the current editor of this blog and the series: “Year of Confusion…Year of Opportunity: 20 Things Changing Emergency Medicine”. Dr. Adinaro can be reached via  @PatersonER and his personal blog: PatersonER.com.

This publication represents the personal opinion of the author and does not reflect the official policy of NJ-ACEP or the American College of Emergency Physicians. You can contact us here.

“Year of Confusion…Year of Opportunity”

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Welcome to the official blog (njemergencydocs.com) of the New Jersey Chapter of the American College of Emergency Physicians (NJ-ACEP)!

This blog is part of our initiative “Year of Confusion…Year of Opportunity”  which is in response to the sea of changes happening nationally to the House of Medicine. Over the next year we will be breaking down many of the issues, trends, concepts, laws, and demographics that are changing our specialty. We will present these topics in a series of blogs entitled            “20 Things Changing Emergency Medicine“.

It has been impossible recently to pick up a newspaper or go online without being inundated with new terms, new acronyms, and new ideas related to the delivery of healthcare. Our goal is get to as many of them as possible. This is a target list of topics but we hope you, the reader, will join in with your own ideas:

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  • Affordable Care Act (Obamacare)
  • Accounting Care Organizations
  • Transition of Care
  • Meaningful Use
  • The Silver Tsunami (Geriatrics)
  • Palliative Medicine
  • The Future of  Medical Education and Workforce Issues
  • Chronic Pain Patients
  • Genetic Medicine
  • Artificial Intelligence (IBM’s Watson)
  • Medical Radiation
  • High Reliability Emergency Medicine
  • Social Media in Medicine
  • Tele (Remote) Medicine
  • Big Data

Our goal is to break down these “Big Picture” issues and provide the emergency physician with three things:

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  • The What
  • The Why
  • The Opportunity (for our specialty)

We look forward to drawing on the talents of our fellow emergency physicians and welcome  as many comments as possible. While we have great leadership in our specialty there is nothing more important than well educated physicians getting out and talking to decision makers (Preserving NJ’s Safety Net). This series is just the one step in that goal.

New posts will come out about twice a month. Press the Follow button above or follow us on twitter (@NJACEP) so you do not miss any of them!

To go to our first post on ACCOUNTABLE CARE ORGANIZATIONS simply press here.