A sideline that grew outside the lines

Hospitalist Stephen Bekanich, MD, talks about starting a successful palliative care program.

When administrators at the University of Utah Health Sciences Center decided that they needed a palliative care service, hospitalist Stephen Bekanich, MD, signed on to lead the program. A few years in, the palliative care service has treated vastly more patients than expected, saved the hospital thousands of dollars and expanded into new areas. Dr. Bekanich recently talked with ACP Hospitalist about how he and his colleagues have made the program a success.

Q: How did your palliative care team get started?

A: A little less than four years ago, our hospital board felt like it would be important to have a palliative care service. Our chief medical officer approached me about what I thought I would need if I were going to start a program. I wrote up a proposal, the hospital liked the proposal and accepted it. We started with myself splitting my time between my hospitalist group and palliative care, one full-time nurse practitioner (NP) who's also boarded in palliative care, a social worker that was half-time, and then my hospitalist group kind of pitched in.

Q: How was your hospitalist group involved in the project?

A: Our group encourages these outside interests or projects. Besides palliative care, we have an anticoagulation service; we have a group of people that do quality improvement; we have someone who does information technology. With all these projects, we help one another out. What that meant for palliative care is over the first year, when I was not rotating on the palliative care service, one of my partners would cover and help the NP and they would also cover on weekends.

To do this within a hospitalist group, you need administrative support. But you also need partners that are going to help you through this. When you try to do this on your own without support, and I've seen colleagues at other centers try to do that, it becomes much more difficult and much more stressful.

Q: What was the project startup like?

A: Before we started, we went to one of the Center to Advance Palliative Care seminars. They predict how many patients you'll see that first year by looking at payer mix and how many beds you have and how many deaths you have. We wound up seeing more than three times [the patients] that they predicted we would. It was very stressful and very difficult to maintain balance and also keep up with all my hospitalist work.

Q: How did you inform the rest of the hospital about the service?

A: We had planned on turning the pager on and just looking at each other and waiting—that didn't happen. The pager just started going off all the time. We were happy and excited about that, but it made us do a whole lot less marketing because we were so much busier than anticipated. From a physician standpoint, we did things like Grand Rounds. I gave noon conferences to all the residents. I sent out emails to all the doctors in the hospital who take care of inpatients here. I got several invitations to different hospital boards, like the trauma board, to educate them. Our NPs have worked tirelessly to go to every nursing unit and give an in-service to all of them. We met with all of the hospital's social workers on multiple occasions. If you get them on your side, it's a really great way to generate business and consults.

Q: How did the finances work?

A: After the first six months, we went back to the hospital board and presented our financial data. At that point, we had saved the hospital over $600,000. We wound up saving money where the hospital's not being paid because these patients have gone past their DRG (diagnosis-related group). The hospital saves money on everything from dialysis to chemotherapy to different types of surgery and medications and studies in radiology. A decreased level of nursing costs, and moving patients out of the ICUs faster and having patients get discharged—that's where the money comes from. We have somebody in hospital finance that works with us and runs all these numbers for us.

Q: What changes were made to the program over time?

A: We got another NP who's full-time. We kind of faded out most of the other hospitalists. I am still a hospitalist, and the palliative care program is based out of our group, but there are only two of us who rotate regularly on the service, along with the two NPs. As things go on, and doctors and nurses and social workers have a better idea of how to work with us and use us, then there's less busywork. At the beginning of these service lines, things are a little bit more hectic and time intensive.

Q: How does your team work on a day-to-day basis?

A: We see patients 365 days a year. The pages go to everybody. There is somebody that we designate at all times as the primary person to answer pages. Consults have to be generated by an attending physician. A lot of times they originate from a nurse or a resident, but the attending physician has to give a nod. On evenings and weekends, we rotate through the call cycle.

We don't take patients away from the referring teams. We consult and work with them. Around a third of our consults are for symptoms. Most of the symptoms are pain-related; the second (most common) would be dyspnea and the third probably anxiety or agitation. A third of our consults are to help set goals of care and help communicate with patients and families. Then the other third of our consults are to help with end-of-life care.

For the most part, we almost always have somebody rotating with us. We rotate students, whether it's medical students, social work students, pharmacy students. The residents rotate with us, mostly internal medicine, but also some other services. The fellows also rotate when it's an important part of their job, so the oncology fellows rotate with us, the anesthesia fellows. We actually do all the consults and have them just observe, just because this can be kind of a touchy subject.

Q: How does the work compare to being a hospitalist?

A: The things that I love are that it's very much like boutique or concierge medicine in that patients are given 24/7 access to us. We spend an enormous amount of time with patients and families. Even when they leave the hospital, a lot of them have adopted us. We still talk to them or even see them socially. I feel very, very close to my patients.

The frustrating part for me compared to being a hospitalist is that with palliative care, because it's a relatively young field, there's just not nearly as much information. I really love that part of being a hospitalist. I love studies. I love data. In palliative care, there are a lot of things that we do in our day-to-day practice and we don't have the evidence to back it up.

Q: What are the future plans for your service?

A: We've started seeing patients in the outpatient arena. We have a clinic one day a week now where we see patients either that we saw in the hospital or new patients that are referred to us from some specialty clinics that we've aligned ourselves with. Because we learned when we opened the floodgates three years ago, we're opening the door slowly with this one.

Q: What are you usually doing for the outpatients?

A: With people that we see from the hospital, the two main things are either to titrate medications—mostly opioids for pain—or to continue to establish goals for care. If someone's been in the hospital for three weeks and they're going to be discharged on Friday and we get consulted on Thursday, it's hard to say, “OK, we need to have all of your wishes. Do you want dialysis? Do you want to come back to the hospital?” all in one session when we've just met them. As far as seeing new patients, it's usually for goals of care. It's going through options and providing information about symptom management, so that they don't feel alone or abandoned.

Q: What else are you planning?

A: Our other big project right now is getting swing beds. We got the hospital to give us two beds. I never imagined how much work it would be to commandeer two rooms. We've found donors that have given us money so that we can remodel these rooms, which look more like hotel suites. All the medical equipment is actually hidden. There's art on the wall, a refrigerator, places for family members to sleep.

When a patient is dying, they will have these palliative care suites to go into (the beds will open up in June of this year). We picked a part of the hospital where the nurses really like palliative care. Now the people who do die in our hospital will be cared for by a group of nurses who are trained in palliative care. When [these rooms] are not in use, they'll be regular hospital beds.