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New study demonstrates effectiveness of serious illness communication in primary care

BRIGHAM AND WOMEN'S HOSPITAL NURSE BARBARA HEALY VISITS PATIENT STEPHEN CHRISTAFONO AT DEUTSCHES ALTENHEIM TUESDAY MORNING
Brigham and Women’s Hospital nurse Barbara J. Healy, R.N. making rounds as part of the Integrated Care Management Program. (lightchaser photography © 2016. Photo courtesy of Brigham and Women’s Hospital)

New study demonstrates effectiveness of serious illness communication in primary care

Boston, Mass – Chronically ill patients in a high-risk management program that implemented structured, communication-based serious illness care had more meaningful and comprehensive conversations with their clinicians about their values and goals of care, according to a new study.

The findings, published in the July issue of Health Affairs, demonstrate that is possible for primary care clinicians and patients to successfully integrate serious illness communication in a primary care setting. Drs. Josh Lakin and Rachelle Bernacki, both Ariadne Labs researchers and palliative care physicians at Brigham and Women’s Hospital and the Dana-Farber Cancer Institute, led the two-year study with high-risk patients enrolled in the Integrated Care Management Program (iCMP) at 14 clinics in the Brigham and Women’s Hospital (BWH) system.

“We are really encouraged to see that this program to increase conversations about patients’ goals and fears in advancing serious illness can be effectively adapted and implemented by primary care clinicians for the benefit of their patients,” said Lakin, the lead author.

Bernacki, senior author added, “What’s most promising about this trial is that we increased meaningful conversations for patients and families about what matters most. We also found that having conversations can be a ‘team sport.’ Most conversations were conducted by multiple members of the team, sharing the benefit and burden of having these difficult conversations.”

The Ariadne Labs Serious Illness Care Program facilitates appropriate, patient-centered conversations between clinicians, seriously ill patients and their families about what matters most to patients in their care. Drawn from best practices in palliative care, the program has four main components: a system to identify patients, training and coaching for clinicians on how to use a structured Serious Illness Conversation Guide, reminders to have the conversations with patients and a system to document the conversations in the electronic health record. The goal is for all patients with serious illness to have better quality conversations with their clinicians, earlier in the course of their illness so medical care and treatment reflects their wishes.

Study authors noted the importance of providing serious illness care in a primary care setting. “Patients and their caregivers in the primary care setting rely on their clinicians to initiate conversations about goals and preferences in serious illness. However, primary care clinicians do not regularly address values and goals with their seriously ill patients.”

Researchers adapted the Serious Illness Care program for the iCMP setting based on feedback from BWH primary care clinicians. Clinicians reported high satisfaction with the training. The program was implemented in six BWH facilities with eight facilities serving as the comparison group.

Patients in the study represented a diverse population from across Boston and all had complex medical conditions. Through the Integrated Care Management Program, each patient is assigned to a nurse care coordinator who works closely with primary care doctors and social workers to help the patients follows a customized care plan.

As part of the study, 230 patients were selected to have the serious illness care conversation. To assess the effectiveness of the Serious Illness Care Program, researchers evaluated the medical records of the 178 patients who died during the study period. They found:

  • For patients who died during the study period, more patients in the intervention group (62 percent) had at least one serious illness conversation compared to the control group (43 percent)
  • For those patients whose conversation was documented, patients in the intervention (44 percent) were more likely to have their conversations recorded in the advance care planning module of their electronic medical record compared to the control group (3 percent)
  • The timing of the conversations was not significantly different between the two groups
  • Conversations for patients in the intervention group were more comprehensive, covering more elements of patient goals and values (2.8 elements) compared to the control group (1.8 elements)
  • Conversations were conducted by multiple team members 42 percent of the time (physicians had conversations alone 37 percent and nurses alone 19 percent)

“Our goal has been to empower primary care physicians, nurses, and social workers to feel comfortable and well-equipped to have these important discussions with patients who are facing serious illness,” said Rebecca Cunningham, MD, medical director, Integrated Care Management Program at Brigham Health. “By providing a comprehensive approach, including patient identification, teamwork and coaching, we have seen how beneficial this can be for both patients and providers.  I have seen the benefits with my own patients, and I’ve heard the same from colleagues, who appreciate building their skills in this area so that we can better understand patients’ values and goals and work together to provide the kind of care that patients hope for at the end of life.”

On Tuesday, July 11, Dr. Bernacki joined a convening organized by Health Affairs at the National Press Club in Washington, DC, featuring panels of journal authors presenting topics on care at the end of life, hospice and palliative care, and more.  Follow this link to find full coverage from the event: http://www.healthaffairs.org/events/2017_07_11_advanced_illness_end_of_life_care/