PROPOSAL TITLE: Enhancing Equity and Value with ED-initiated Palliative Care Consults 

PROJECT LEAD(S): Michaela Gonzalez MD and Susan Lambe MD

EXECUTIVE SPONSOR(S): An executive sponsor is a senior leader(s) in your clinical or operational area who is responsible for the overall success of the project and can assist with the removal of systems barriers. Project teams must remain in regular contact with their executive sponsor(s) throughout the project year. 

Maria Raven, MD, MPH, Professor of Emergency Medicine, Vice Chair Department of Emergency Medicine

ABSTRACT - One paragraph summary of your proposed initiative – Limit 1500 characters (with spaces)

In November 2022, the American College of Emergency Physician (ACEP) declared emergency department (ED) boarding a public health emergency as “Our nation’s safety net is on the verge of breaking beyond repair; EDs are gridlocked and overwhelmed.” As our population continues to live longer with chronic end stage diseases, the number of individuals requiring emergency care services continues to rise. Many of these patients have unmet palliative care needs: symptom burden, functional decline, or acute prognostic deterioration. However, the capacity for emergency medicine (EM) providers to meet these surging needs is limited. Previous studies have demonstrated that initiating palliative care (PC) consults in the ED have markedly reduced inpatient length of stay (LOS), which is associated with decreased hospital costs. Based on the literature, we expect that an ED-embedded palliative care provider will reduce hospital length of stay and cost of care, and improve quality of patient care and experience. Our project will embed a single palliative care provider in the main Parnassus ED during high census times (weekdays 11a-7p), and measure the impact of that intervention on patient experience and LOS.

TEAM - Core implementation team members and titles

 Confirmed Team Members:

1. Maria Raven, MD, MPH - Chief of Emergency Medicine, UCSF Parnassus ED

2. Laura Schoenherr, MD- Associate Division Chief of Inpatient Palliative Care Services

3. Janet Ho, MD- Medical Director of Inpatient Palliative Care Service at Parnassus

4. Maggie Jones, MD- Professor of Medicine, UCSF Triage Hospitalist Service

5. James Hardy, MD - Associate Professor of Emergency Medicine, Assistant Director UCSF’s Age-Friendly Emergency Department

6. Karen Martinez, BScN, RN, CEN, Assistant Unit Director, Parnassus Emergency Department

We plan to recruit team members from Case Management and Utilization Management in the next phase of the project.

PROBLEM - Provide background of the current state and describe the problem or gap in performance, including the presence of any equity gaps. What are the financial and operational metrics that provide evidence of this problem/performance gap? Why address this problem now? 

 In November 2022, the American College of Emergency Physician (ACEP) declared emergency department (ED) boarding a public health emergency as “Our nation’s safety net is on the verge of breaking beyond repair; EDs are gridlocked and overwhelmed.” UCSF’s Parnassus ED is no exception to boarding challenges, with year over year increases in ED boarding that correlate directly with declining Patient Satisfaction scores and increasing UCSF patients who leave the ED without being seen by a provider.  In addition, as our population continues to live longer with chronic end stage diseases, the number of individuals requiring emergency care services continues to rise. Many of these patients have unmet palliative care needs: symptom burden, functional decline, or acute prognostic deterioration. However, the capacity for emergency medicine (EM) providers to meet these surging needs is limited. Previous studies have demonstrated that early initiation of palliative care consults in the inpatient setting and in the ED have improved care quality in the areas of symptom and pain management, patient and family satisfaction, and advance care planning due to improved clarification of treatment goals and adherence to patient preferences. These studies have also demonstrated financial benefits by reducing hospital LOS, thus decreasing daily costs. 

Previous investigators, working in a similar, tertiary ED setting, reported a marked decrease in median LOS when a palliative care consult was initiated in the ED compared with inpatient consults (3d vs 7d for acute care admissions and 3d vs 8d for ICU patients).  A primary goal of our project is to determine whether a similar reduction in LOS can be achieved at UCSF Parnassus.  Based on the FY23 estimate of variable direct cost per day of $1,642, cost savings could potentially be as high as $6,568 ($1,642 cost per day x 4 day reduction in LOS) per patient with ED-initiated PC consult.  We expect the savings would be even higher for a potentially ICU-bound ED patient re-routed to receive palliative care in an acute care setting.

This pathway fulfills Caring Wisely’s central aims of improving access to care, improving hospital throughput and reducing excess inpatient bed days. An ED-embedded palliative care service will improve quality patient care and experiences near the end of life by initiating early palliative care as well as improving health equity by creating access to palliative care in a safety net setting. Shorter admissions have potential to decompress the hospital and open up ED and inpatient beds for patients seeking specialized care at UCSF.  This is a proof-of-concept study that will guide the transformation of palliative care services in the ED; and may help change current practice patterns and habits at UCSF’s emergency department and other emergency departments. Additionally, it serves to meet 1 of the 3 health needs identified in UCSF's 2022 Community Needs Health Assessment by addressing improving access to care. 

TARGET -  What is the SMARTIE (specific, measurable, achievable, relevant, timebound, inclusive, equitable) goal?  What are the expected benefits, both qualitative and quantitative?

The goals of this project are to reduce costs by reducing hospital length of stay, improve quality of care and patient experience for seriously ill patients in the ED by democratizing palliative care services, and improve health care team well-being by appropriately re-distributing patient care to team members with specialized training.

• Qualitative Benefits: Seriously ill patients will benefit from expedited palliative care assessments and treatments, which will address symptom burden, functional decline, or acute prognostic deterioration, thus reducing the hospital length of stay and hospital cost.

• Quantitative Benefits: Investigators at similar, tertiary care hospitals reported markedly reduced LOS for patients with ED-initiated palliative care consults compared with consults initiated on inpatients.  Our project will measure whether a similar reduction in LOS is obtainable at UCSF.  Starting July 2024, Dr. Gonzalez will be a Palliative Care Fellow at UCSF and has volunteered to donate her elective time to piloting this project.    

GAPS - Why does the problem exist?  Describe system issues; technological gaps; educational gaps

Patients “boarding” in the ED is defined as patients who are admitted to the hospital but remain in the ED waiting for an impatient bed or transfer to another hospital. Boarding leads to ambulance diversion, increased adverse events, preventable medical errors, lower patient satisfaction, violent episodes in the ED, emergency physician and staff burnout, and higher overall health care costs. It is complex and multifactorial, thus requiring an innovative approach to help address the unmet needs of this fragile population (those with end stage illnesses) while being proactive in an overburdened system (emergency departments).

There are notable disparities in accessing palliative care, especially among minority groups. While the intersection of emergency and palliative medicine has become more apparent and accepted over the last decade, there is a still significant care gap when accessing palliative care within health care systems. In practice, the ED frequently cares for vulnerable, PC-appropriate patients, many at the end of life or with life-limiting illnesses. Some of the limitations to accessing palliative care in the ED include cultural differences, inadequate training of ED clinicians, and logistical barriers like time, space and divided attention. Many studies have recognized that the PC model fits well in the ED, but limited time and divided attention are challenges that are becoming increasingly difficult to overcome in our current healthcare climate.

INTERVENTION - Describe your proposed intervention and rationale for approach, and include a plan to measure and close any equity gaps. Describe your practice setting and target population (e.g. department, unit, clinic, patient characteristics, diagnosis group, procedural group, provider characteristics, staff characteristics, etc.). Describe potential barriers to implementation. What are the possible adverse outcomes that may occur that may affect quality of care and patient safety as a result of your proposed intervention? 

• Intervention:  A single palliative care provider will be embedded in the main ED daily from 11a-7p on weekdays.  Based on existing literature, we believe there is an opportunity for up to 1-3 consults per shift.

• Rationale: This strategy was reported to be successful in improving patient experience and reducing LOS in a similar volume, tertiary-care ED in California 

• Practice Setting:  Parnassus Emergency Department

• Target Population: Patients who receive Palliative Care consults in the ED by an embedded palliative care provider.  Our control will be patients who receive palliative care consults in inpatient settings at Parnassus.

• Equity Gaps:  ED patients are more likely to be experiencing homelessness, have limited English proficiency, substance use disorders and behavioral health challenges. Providing prompt access to palliative care will improve health equity for these very vulnerable patients. An analysis of the impact of this intervention on improving health equity will be included in our project.  

• Barriers to Implementation:  

• Salary support for an ED-based palliative care provider is a potential future barrier. For our pilot, Dr. Gonzalez, a Palliative Care Fellow at UCSF starting July 2024, has volunteered to serve as our inaugural ED-embedded palliative care provider during her elective time.  Drs. Ho and Schoenherr have committed to supporting Dr. Gonzalez in this effort.  Additional palliative care fellows will be invited to participate on a voluntary basis.  

• One potential challenge in the ED is limited physical space for providers, so a logistical problem will be determining the optimal workstation for an additional provider.   Dr. Raven and Karen Martinez, RN, are committed to finding appropriate space for this work during our pilot.

• Adverse Outcomes:  We were not able to identify any direct patient care-related adverse outcomes for ED- versus inpatient-initiated palliative care consults. 

PROPOSED EHR MODIFICATIONSNote: EHR modifications are NOT required for a winning proposal

We are not seeking an EHR modification.  We plan to use existing APeX tools to complete this project.

RETURN ON INVESTMENT (ROI) - Estimated direct cost savings and/or revenue enhancement to the health system from the proposed project

COST:

• This is a pilot proposal.  Dr. Gonzalez will donate her PC fellowship elective time (2 months) to piloting this project at no cost.  If the pilot is successful, options to continue the position might include:

• Discussion about an ED-based palliative fellowship rotation or internal moonlighting opportunity (expected cost $500-$700 per shift)

• Exploration of an ED-based palliative advanced practice provider (expected cost $500-$700 per shift)

• The palliative care service will also have an opportunity for increased revenue via ED consults performed by an additional provider, potentially increasing consult volume.  At a similar institution, the ED-embedded PC consultant cared for 2.2 patients per shift.

• Outside investigators have reported an overall 6.7x ROI in a similar tertiary ED setting using this protocol

SUSTAINABILITY - If successful, how will this intervention be sustained beyond the funding year?  Who are the key UCSF leaders/process owners that can plan for and budget operational resources to keep the intervention going after the project year?

If the intervention is successful, funding would be required for salary support for the ED-embedded palliative providers.  Though our project has strong support from both Emergency Medicine, Hospital Medicine and Palliative Care leaders, given UCSF’s current financial constraints we currently do not have a commitment to provide ongoing financial support.  Determining funding for ongoing support is a goal if our project is selected to enter the next phase of the Caring Wisely review process.

BUDGET - Line-item budget up to $50,000 - Briefly identify key areas of the project that will require funding, e.g., salaries, software, printing, etc

Project management - $1,000

Analytic support - $3,000

References:

Koffman, J., Shapiro, G.K. & Schulz-Quach, C. Enhancing equity and diversity in palliative care clinical practice, research and education. BMC Palliat Care 22, 64 (2023). https://doi.org/10.1186/s12904-023-01185-6

Neugarten, Carter et al. “The Value of Embedded Palliative Care in the Emergency Department.” Academic emergency medicine 30.8 (2023): 870–873. Web.

Wang, David H, and Ryan Heidt. “Emergency Department Embedded Palliative Care Service Creates Value for Health Systems.” Journal of palliative medicine 26.5 (2023): 646–652. Web.

Wang, David H., and Ryan Heidt. “Emergency Department Admission Triggers for Palliative Consultation May Decrease Length of Stay and Costs.” Journal of palliative medicine 24.4 (2021): 554–560. Web.

Wang, David H. “Beyond Code Status: Palliative Care Begins in the Emergency Department.” Annals of emergency medicine 69.4 (2017): 437–443. Web.