PM2016: Community Partnerships Are Indispensable Partners for Successful Hospital-based Pediatric Palliative Care Programs

Purpose/Objectives: To develop a seamless program "without physical boundaries" between tertiary pediatric referral hospitals and an established community-based hospice (HPM) organization. The hospital HPM team has limited reach and impact without a strong partnership with the community-based provider.

Design/Methods: Planning involved leadership of a quaternary HPM service and a community HPM service, Capital Caring Kids (CCK), serving Northern Virginia, Washington DC and Southern Maryland. Biweekly virtual rounds provided continuity, updates, and assured completely collaborative care. Our "Virtual Patient Care Rounds" (VPCR) were instrumental in sharing information between home and hospital, assuring families we functioned as one team. Sustained commitment of hospital personnel and leadership of CCK were essential. An essential, full-time, dedicated liaison/coordinator provided a seamless administrative conduit between CCK and hospital team. After one year, the second major referral center was invited to join their own biweekly VPCR. We serve three tertiary pediatric facilities each with unique personnel and capabilities. Yet, to assure that a child cared for by CCK receives the same quality and quantity of care regardless of the referral hospital, CCK engaged a dedicated, experienced pediatric HPM physician (HMD) to liaise with each organization and provide a consistent level of care for the patients. The community HMD and nurses strive to execute the plans of the referring specialists assuring high standards of care. The CCK nursing staff and HMD guarantee safety, and provide a common link between home and hospital teams, so that families know we are all on the same page and timely communications are maintained.

Results: The VPCR program has existed ~4 years and includes 50 children referred by three academic tertiary centers in our catchment area. Staff consists of six RN case managers who cover the territory and work closely with the two pediatric HMDs, who are available 24/7. Nursing satisfaction is rated high with nurses feeling supported by the HMDs and families knowing that their primary specialty provides and home hospice team are speaking with one another frequently. Concurrent care reimbursement provides financial stable and consistently achieving budget over the last three years, which has allowed the engagement of a second physician and enhanced psychosocial support services. The referring hospital teams appreciate the close collaboration and open communication about their patients, which has increased the willingness to referral early.

Conclusion/Discussion: Building upon virtual collaborative rounding, we have created a robust large community-wide program that has enhanced the quality of care provided by one large community organization to patients referred from three independent academic children's hospitals. The program is recognized region wide for its consistent, high-quality care with open dialog between hospital and home teams. This model lends itself to many community settings throughout the country and can be replicated in a cost-effective and family-satisfying manner.