Washington Rural Palliative Care Initiative Integration of Palliative

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Washington Rural Palliative Care Initiative Integration of Palliative Care in Rural Communities Pat Justis,

Washington Rural Palliative Care Initiative Integration of Palliative Care in Rural Communities Pat Justis, MA & Stephanie Carpenter, RN, CNO WSHPCO, October 10, 2017

Objectives 1. List three characteristics of rural health systems that call for a different

Objectives 1. List three characteristics of rural health systems that call for a different approach to palliative care and describe the model proposed for rural integration of palliative services in WA State. 2. Describe specific strategies that organizations can use to deliver palliative services to rural communities. 3. Discuss lessons learned to date in a rural healthcare system in rural WA.

Rural? Comparable data? • There at least six different ways to define rural-and measure

Rural? Comparable data? • There at least six different ways to define rural-and measure health risks and outcomes. • County level-used for some purposes but imposes inaccuracies. (31 of 39 counties labeled rural). • We use RUCA for most work which is at census track level or zip code, with 10 codes and 21 secondary codes, four categories. • Urban, suburban, large rural, small rural

Overall Washington • Depending on classification system used, 12. 3 percent to 16 percent

Overall Washington • Depending on classification system used, 12. 3 percent to 16 percent of residents live in rural areas. • Also various ways to classify “Frontier” criteria and unit of geography. • Most simple= population density of seven or fewer people per square mile. ( Federal Public Law 94 -171) • WA: Skamania, Columbia, Garfield, Lincoln, Ferry

The further you are from a metro area the greater the health disparities… •

The further you are from a metro area the greater the health disparities… • Older and younger with fewer working age adults • Poorer • • • More obese, more tobacco use More with unmet medical needs Fewer with healthcare insurance Fewer with personal healthcare provider Fewer with dental care Fewer utilize preventive care or services.

The further you are from a metro area the greater… …the travel time for

The further you are from a metro area the greater… …the travel time for home health and hospice teams.

What are other challenges for rural care delivery?

What are other challenges for rural care delivery?

Rural Risks Longer waits for specialty services, sometimes primary care Risk of tertiary transfers

Rural Risks Longer waits for specialty services, sometimes primary care Risk of tertiary transfers rip apart families at vulnerable times Less exposure to palliative services, may be unaware of choice Disruption from workforce turnover and shortages Fewer formal community supports for other needs (but often greater informal) • Fiscal sustainability crisis • • •

There is not enough volume or resources… • …to support free standing inpatient/outpatient palliative

There is not enough volume or resources… • …to support free standing inpatient/outpatient palliative services in every rural community. • The goal: no duplication, filling gaps and coordinating across programs and services • So, what will work and operate in collaboration with home health and hospice agencies?

Washington Rural Palliative Care Initiative objectives • Assist rural health systems and communities to

Washington Rural Palliative Care Initiative objectives • Assist rural health systems and communities to integrate palliative care in multiple settings, to better serve patients and families in rural communities. • Use the Model for Improvement to test and refine changes and assess measurable improvements to selected process and outcomes measures. • Develop funding models for sustainable services

Building the vision • Chartered Palliative Care-Rural Health Integration Advisory Team, Met four times

Building the vision • Chartered Palliative Care-Rural Health Integration Advisory Team, Met four times between 10/2016 and 3/2017 • Composed of rural health early adopters from CAHS and RHCS, experts in palliative care, experts in telemedicine, a rural hospice, associations, DOH, physicians, nurses, care managers, educators and more.

Rural Palliative Care in Minnesota • Stratis Health (Quality Improvement Organization) initiated work on

Rural Palliative Care in Minnesota • Stratis Health (Quality Improvement Organization) initiated work on rural palliative care in 2009 and now have about 30 rural communities offering some level of palliative care service. • They increased benefits for palliative care in the state. • Their approach is community based and owned. • Wonderful resources below or Google Stratis Health Rural Palliative Care http: //www. stratishealth. org/expertise/longterm/palliative. html

Piper Hawley, Bmed, FRPC University of British Columbia, Head of Palliative Care Division

Piper Hawley, Bmed, FRPC University of British Columbia, Head of Palliative Care Division

The Model Direct Telemedicine services for patient/family Community engagement and education Project Echo- or

The Model Direct Telemedicine services for patient/family Community engagement and education Project Echo- or similar case consultation RHCs & CAHs in coordination with HH & H and communities Clinical team culture change training and technical assistance Rural Centers of Excellence Begin with in-kind contributions and develop sustainable funding streams Act Plan Study Do

The Telehealth developmental path… Home based Health organization sited direct clinical telemedicine Case consultation/training

The Telehealth developmental path… Home based Health organization sited direct clinical telemedicine Case consultation/training

Making it concrete • A primary care Rural Health • A community pilots in

Making it concrete • A primary care Rural Health • A community pilots in their Clinic team offer primary home health agency, offering palliative care and knows how palliative care consults to connect to the community team. • Volunteer Retired (and not • The Critical Access Hospital retired) Professionals receive identifies patients who may training, ongoing support and benefit from a palliative care supervision to offer home based consultation and can arrange visits working in tight for that by telehealth or directly to the patient and family for collaboration with home health telemedicine. and hospice

Work progress Advisory team conceptual model Complete Work groups Implementation planning and cohort selection

Work progress Advisory team conceptual model Complete Work groups Implementation planning and cohort selection Testing and refinement in six rural communities Spread to additional communities Training for WA rural health communities

Our first cohort • • Pullman Regional Hospital-Pullman Whitman Hospital-Colfax Columbia County Health System-Dayton

Our first cohort • • Pullman Regional Hospital-Pullman Whitman Hospital-Colfax Columbia County Health System-Dayton Columbia Basin Hospital-Ephrata Jefferson Health Services-Port Townsend The Lookout Coalition-Twisp Newport Hospital and Health Services (delayed entry)

Northwest Rural Health Conference March 26 -28, 2018 Davenport Grand, Spokane Save the date

Northwest Rural Health Conference March 26 -28, 2018 Davenport Grand, Spokane Save the date

Thanks to the Palliative Care-Rural Health Integration Advisory Team Northwest Telehealth, Northwest Regional Telehealth

Thanks to the Palliative Care-Rural Health Integration Advisory Team Northwest Telehealth, Northwest Regional Telehealth Resource Center, Family Care Network, Northwest Rural Health Network, Heartlinks Hospice and Palliative Care, Washington Hospice and Palliative Care Organization, Home Care Association of Washington, Newport Hospital and Health Services, Pullman Regional Hospital, Whitman Hospital, Washington State Department of Health State Office of Rural Health, University of Washington (WWAMI, Family Medicine, Palliative Care), Washington State University Elson S. Floyd College of Medicine, Providence Health System, Amerigroup, Washington State Hospital Association, Qualis Health, and Stratis Health Newly invited members: Columbia County Health System, The Lookout Coalition, Columbia Basin Hospital, Jefferson Health System