Comforting the chronically ill

David K. Jones, MD, takes palliative care up a notch.

Hospitalist David K. Jones, MD, is in his comfort zone. As medical director of palliative care at Mercy Medical Center in Des Moines, Iowa, he's committed to bringing comfort to chronically ill patients, as well as a comfortable bottom line to health care costs. His pilot, the Home Palliative Care project, which is supported by a local insurance company, is doing just that.

“Over the course of a year, with less than 50 patients, we showed improved outcomes for patients and a cost savings of over $2 million,” Dr. Jones said. The results have already gained the attention of a second insurance carrier, which expressed interest in providing palliative care coverage.

David K Jones MD
David K. Jones, MD

With his team of social workers, nurses, hospitalist Erin Baldos, MD, and oncology nurse-coordinator Dannette Hanson, Dr. Jones addresses the needs and goals of people of all ages with chronic illnesses at any stage in their lives.

“Palliative care focuses on comfort … and symptom management, with the goal of keeping patients more comfortably healthy and out of the hospital,” Dr. Jones said.

The road to comfort

Following medical school and a residency in internal medicine at the University of Kansas, Dr. Jones helped create a hospitalist program at St. John's Hospital in Joplin, Missouri. While at St. John's, Dr. Jones was introduced to the hospital's palliative care program, which offered mostly comfort and end-of-life care.

After moving to Des Moines, Dr. Jones expanded Mercy's limited palliative care division to care for patients with chronic conditions. It was a natural fit with his hospitalist practice.

“One reason the hospitalist movement has taken off is because hospitalists have more time to listen to people. Palliative care takes this to yet another level. We listen to what patients say their needs are, and help work out a plan to meet those needs,” Dr. Jones explained. “And it fit my personality to sit with folks, talk about these things, and develop a plan together.”

At Mercy, consults by the palliative care team are requested by a physician or care manager. Most often this occurs only after it's clear the patient is struggling (e.g., frequent ED visits) or when the patient and/or family questions the patient's medical care or prognosis, although Dr. Jones would like to see more formal criteria applied. “Ideally, there should be diagnostic triggers, such as stage 3 CHF, resulting in a consult,” he said.

Developing a plan for these chronically ill patients can be challenging. Many are hospitalized frequently because they don't have the resources or skills for effective home care. “Finding a way to bridge that gap and head off acute exacerbations of their conditions is how we help keep them out of the hospital, and improve their quality of life,” said Dr. Jones.

The solutions employed by his pilot run the gamut. For example, although a goal of being completely pain-free may not be reasonable for a diabetic man with significant pain from peripheral neuropathy, a plan might include referring him to a hospital pain service and/or pastoral care, recommending medication adjustments, assessing the home situation to minimize falls, and providing patient education and a contact for times the patient has trouble and can't wait two weeks for a doctor appointment.

“These cases are work-intensive, and take a lot of listening and figuring things out. But having an outstanding outcome is incredibly fulfilling,” said Dr. Jones, who has a drawer full of thank you notes from patients' families testifying to their appreciation of his efforts.

Heart of Mercy Rounds

Dr. Jones has received similar appreciation from the hospital's staff for starting Heart of Mercy Rounds, a confidential venue for health care providers to discuss job-related stress. Last year, a young person passed away in Mercy's ED. “It was a pretty nasty case that was traumatic for many people,” said Dr. Jones. “It made me wonder how [the staff] deals with this kind of thing. When I asked around, the answer was, ‘Yeah, well, we'll meet at the bar later.’ I thought there had to be a healthier way to go about discussing these stressful parts of what we do.”

Dr. Jones found the way in his monthly Heart of Mercy Rounds, which he holds for physician, nursing, social work and pastoral staff to discuss health care issues they find stressful.

While physicians are not as involved in the Rounds as others—”Docs are less touchy-feely about those sorts of things,” said Dr. Jones—they overwhelmingly support the Home Palliative Care program.

“Palliative care allows patients a better quality of life, and autonomy in their care and goals. Health care providers who don't have the skill set to talk with people about difficult decisions appreciate someone with this skill set taking part in the dialogue,” said Dr. Jones.