Overview

The University of Southern California (USC) Section of Palliative Medicine and CareMore Health System collaborated to create a ‘train the trainer’ model to improve the skill and comfort level of generalist physicians in delivering palliative care.

Organization Name

Los Angeles County+USC Medical Center and CareMore Health System

Organization Type

• Academic Medical Center
• Integrated healthcare system/network

National/Policy Context

• There has been increased demand and supply for palliative care in the United States due to the aging of the population and the fact that more people are living with chronic disease. Given this, the field of palliative care has grown rapidly over the past decades with an increase in hospital-based palliative care services by 138% from 2000 to 2011.
• However, there has been a growing need for the parallel development of community-based programs to bridge care transitions, as well as providers to staff these programs. Though palliative care is a growing field, there has been a shortage of fellowship-trained physicians. In fact, current estimates report that there is a projected shortage of 18,000 physicians and <250 fellowship-trained physicians entering the field annually.
• One solution for a sustainable model of palliative care delivery is the concept of primary and other non-palliative specialist clinicians providing uncomplicated primary palliative care. However, these clinicians often lack knowledge and confidence due to lack of exposure to palliative care during training. They also often face lack of financial incentives, especially in fee-for-service environments. Nevertheless, health care is moving towards rewarding value-based care, and thus, training such physicians in basic palliative skills will increase value.

Local/Organizational Context

• CareMore Health is a multi-state integrated health delivery system targeting high-risk seniors with chronic illnesses who would benefit from palliative care.
• At CareMore, a company-wide initiative to improve advance care planning (ACP) in the comprehensive care model that already exists within the company has been implemented.
• This intervention was initially designed for CareMore “extensivists”, who specifically see CareMore members both in the hospital as a hospitalist and also in nursing homes and on an outpatient basis. These physicians see CareMore’s sickest and frailest patients. The subsequent trainings that have been or will be implemented target not only this group of doctors, but the advanced practice clinicians and some PCP’s who see a more upstream, healthier population.

Patient Population Served and Payor Information

• LAC+USC Medical Center provides healthcare services to the urban underserved who are on Medicaid or uninsured in Los Angeles County.
• CareMore Health System provides healthcare services for those on Medicare and Medicaid, with a primary focus on high-risk geriatric patients with chronic illnesses.

Leadership

• Dr. Sachin Jain, the CEO of CareMore Health System, initiated the project with Dr. Michael Hochman, the director of the Gehr Family Center for Implementation Science.
• Dr. Carin van Zyl, director of the Adult and Pediatric Palliative Care team at LAC+USC Medical Center, designed a palliative care training program for CareMore generalist physicians.
• Dr. Archita Sood, a CareMore hospitalist, was the first rotator through this program who returned to CareMore to apply the knowledge in her practice as well as train CareMore physicians and nurse practitioners.

Funding

N/A

Research + Planning

• Various palliative care fellowship training models and curriculums were compared. Ultimately, a “see one, do one, teach one” approach was adopted over traditional lectures and powerpoints to create an experiential course for the USC program.
• Scheduling logistics and credentialing were undertaken to allow the CareMore physician to train and provide care at USC during the 8-week course.

Tools or Products Developed

See training section

Training

• • A CareMore physician trainer participated in an 8-week intensive experiential course at USC under the supervision of a USC board-certified palliative care physician. During this course they learned basic palliative care skills at the bedside, more complex symptoms management, and communication skills. The course consisted of:
    • One-on-one didactics with the palliative care mentor
    • Supervised, then later independent, palliative care consultations, including complex family meetings on the inpatient medical, surgical, and intensive care units of USC-LAC Hospital
    • Participation in daily interdisciplinary palliative care rounds
    • Palliative care conferences
    • Journal club meetings
  • The physician trainer then returned to CareMore to use this knowledge in their practice as well as train community-based physicians and nurse practitioners at CareMore.
    • After the period of site-based training, the trainer had continued communication with the palliative care mentor for advice ranging from specific case-based questions to assistance with designing training tactics for clinicians in the community-based health care system.
    • Training was tailored to different levels depending on the knowledge base of the providers and the degree of complexity of patients managed. Advanced skills were taught to teams with more complex patients, while more basic ones were taught to those with patients’ whose needs were minimal.
  • A training series on ACP was developed by the “train-the-trainer physician,” or the initial CareMore physician who trained at USC (see Figure 1). It was launched to all Advance Practice Clinicians and physicians who provide routine care to CareMore members. It includes:
    • Pre-test
    • Series of video modules
    • Series of role-play sessions
    • Post-test
  • Further training has been provided on an ongoing basis in the form interactive micro-learning sessions, where high-yield palliative care pearls and up-to-date evidence in the field are shared with clinicians during recurrent meetings
    • More advanced generalists received training on opioid prescribing in frail populations and on complex goals of care discussions with patients with advanced illness.
    • The USC palliative care mentor was available during some of these sessions to complement training.

Figure 1: Dispersion of Palliative Core Skills Via a Train-The-Trainer Model (as in NEJM Catalyst article)

Tech Involved

• Cerner
• Desktop computer
• Paper & pen

Team Members Involved

• NPs
• Physicians

Workflow Steps

• Physicians are involved in an 8-week training program (see Training section).
• After training is completed, the physicians’ daily workflow is not changed, although their ability to manage palliative care patients and provide training to the palliative care team improved.

Budget Details

Time that CareMore physician spent training (approximately 240 hours per training) was clinical time lost at CareMore.

Where We Are

This intervention began July 2017 and is currently ongoing.

Outcomes

While outcomes have not yet been reported (expected at the end of 2019), CareMore is currently tracking the following:

• Quantitative metrics:
  • Training all clinicians in effective advance care planning and advance directive document completion:
    • CareMore has successfully created and implemented a virtual training across the organization.
  • Completion of advance directives
  • Physician or medical orders for life-sustaining treatment (POLST/MOLST)
  • Utilization of acute care and ICU resources
  • Hospice utilization
    • More than 55% of patients at CareMore now die while on hospice care, which CareMore aims to increase to at least 70%.
    • Increased utilization of hospice is an expected outcome of this training since there will be a greater focus on palliative care earlier in the patient’s serious illness trajectory.
• Qualitative metrics (based on survey data)
  • Clinician or Patient Satisfaction
    • Patient satisfaction
    • Provider comfort
  • Health system loyalty: CareMore members refer their own family members to CareMore
    • Difficult to track, but powerful measurement

Benefits

• Training clinicians to train fellow clinicians in high-quality palliative care practices dramatically increased access to non-hospital-based palliative care in the community.
• The program alleviates anxiety in generalists who, with the training, are now more comfortable providing palliative care, while liberating palliative care team to focus on specialized care where and when it is truly needed.

Unique Challenges

• Attention should be paid as the training practices move further away from the original intensive training, to avoid a dilutional effect on the quality of the original content.
• This model cannot replace expertise of fellowship-trained specialists, but it can close the skills gap among primary providers.

Personnel Challenges

• Credentialing the CareMore physician to practice at USC and blocking them out for an 8-week period were challenges (see “Research and Planning” and “Budget Details”). 

Sources

• Back to the Future? NEJM Catalyst. Available at: https://catalyst.nejm.org/back-future-palliative-care-mentor/
• Conversations with Dr. Van Zyl and Dr. Hochman, input from Dr. Sood