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The strongest evidence for the impact of palliative care is for integration palliative care earlier in the disease course and in the outpatient setting. Thus, Tufts MC is committed to providing fellows with a robust outpatient educational experience that prepares them to deliver palliative care in the ambulatory setting. The outpatient palliative care practice is a growing with over 1,000 encounters in 2022. Palliative care providers see patients in clinics embedded in oncology, nephrology, and pulmonary. Patients are referred for pain, non-pain symptom management, psychosocial support and advance care planning.
Fellows will be assigned a half-day clinic session each week. The fellow is expected to prepare for these visits in advance. All patients will be precepted with an attending physician. The fellow is expected to communicate recommendations to the referring provider, prescribe medications, do phone call follow-up when necessary and complete documentation is a timely fashion. To ensure longitudinal care, patients will be booked with the fellow whenever possible. If patients from their clinic are hospitalized or referred to hospice, fellows will be encouraged to see them in these settings.
In addition to the longitudinal clinic, fellows will have multiple weeklong outpatient immersion experience throughout the year. During these weeks, the fellow will see patients in clinic for several half-day sessions. This will allow them to see patients in a setting outside their longitudinal clinic and ensure diversity of diagnoses and experience in the ambulatory setting. They will have the opportunity to visit longitudinal clinic patients in another setting (home, long-term care, hospital). During these weeks, didactics will focus on ambulatory topics, such as opioid stewardship, practical aspects of prescribing (e.g costs, prior authorization), prominent outpatient symptom management (e.g. fatigue, anorexia, sleep disorder), the assessment and facilitation of adaptive coping and logistics of telemedicine. Fellows will be asked to present
Tufts Medicine Care at Home, previously Merrimack Valley Hospice, an agency of Home Health Foundation, serves as the site for the home hospice rotation. Deeply committed to providing emotional and physical support, the clinical team includes the Hospice Medical Director (HMD) and Associate Medical Directors, Nurse Practitioners, nurses, social workers, home health aides, bereavement counselors, a volunteer coordinator, spiritual care counselors, volunteers, and other therapists, including music therapy, as needed. The Hospice Medical Director and Associate Medical Directors have all served in academic appointments and worked for at least fifteen years in the clinical practice of hospice and palliative care. Merrimack Valley Hospice is proud to participate as a level three member in the We Honor Veterans program, a program of the National Hospice and Palliative Care Organization in collaboration with the Department of Veterans Affairs. During their rotation, fellows with will make home visits primarily in conjunction with one of the hospice nurses and/or the Hospice Medical Director or Associate Medical Director, and less frequently with another team member. Occasionally toward the end of the rotation, fellows will visit patient homes independently. Fellows will participate in weekly IDT meetings, presenting patients they have seen. The didactic curriculum will include lectures on syndrome of imminently dying, non-oral routes of medication administration. The hospice medical director will meet each fellow to review key components of hospice administration, including regulatory, administrative, legal, ethical competencies, cost-effective policies and clinical skills appropriate for hospice patients.
Home Health Foundation
High Pointe House has 21 private suites for patients along with spacious common areas, including a kitchen, play area, library, and garden, to support the needs of families. High Pointe provides both general inpatient (GIP) level of care and routine hospice care for patient unable to receive such care at home. Patients on GIP have intense medical and/or nursing needs, such as management of pain or other acute symptoms requiring IV medications. The site has 24/7 coverage to address these complex symptoms. Fellows will round on GIP patients with the supervising physician as well as spend time with various team members, including the on-site bereavement and spiritual counselors. The experience will educate them in how to address all aspects – physical, spiritual, psychological, existential – of suffering in patients at the end of life.
High Pointe House
The palliative care team for the hospice and palliative care unit consists of a physician, nurse practitioner, social worker, nurse manager, chaplain, speech pathologist, pharmacist, nutritionist, recreational therapist, and kinesiotherapist. The hospice and palliative care unit cares for 15 veterans and accepts patients for both end-of-life care and for ongoing symptom management and support during palliative chemotherapy or other supportive care.
During this rotation the fellow will round daily with the care team, including the physician, nurse practitioner, and charge nurse. The fellow will initially manage patients and accept admissions with close supervision from the attending physician and will move to a more independent model as the year progresses. The fellow will learn how to triage admission requests, coordinate family meetings, run an IDT meeting, develop a care plan, and discharge patients from hospice. The team meets for IDT and care plans weekly and the fellow will have the opportunity to run this meeting toward the end of the rotation. The fellow will be expected to complete admission notes and daily progress notes.
The fellow will have the opportunity to work with other learners including psychiatry interns, physician assistant interns, psychology and pharmacy interns. The fellow will have the opportunity to provide education to the team and will be expected to provide education on one topic of interest during the rotation.
HPM fellows will gain exposure and expertise with pediatric patients from a variety of sources. They will see inpatient consults from the neonatal intensive care unit (NICU), precepted by Dr. Tamara Vesel a pediatric palliative care physician and the Division Chief. They will also rotate at the New England Pediatric Care nursing home, an 80-bed facility designed for children who are medically complex and have severe cognitive and neurological impairments. During this experience, they will be supervised by Dr. Harry Webster, a pediatric physiatrist and Medical Director of New England Pediatric Care. They will see patients with Dr. Webster in clinic and they will round with other members of the inter-disciplinary team (e.g. physical therapist, occupational therapists, social workers, speech language pathologist and nurses) to learn their role in caring for their seriously ill children. Finally, fellows will see children and young adults when they are referred for hospice care with Tufts Medicine Care at Home or to the High Pointe inpatient hospice house. Patients from NEPC referred to hospice, most commonly are seen by Tufts Medicine Care at Home which would allow fellows to see patients at two different locations and stages in their illness trajectory.
Each fellow has the opportunity to spend at least 4 weeks in a focused experience. For fellows interested in an academic career, this is a chance to more forward a scholarly project, which can be an educational endeavor, a quality improvement project, a clinical innovation or other scholarly work. The fellowship will provide guidance and mentoring and help craft time to maximize productivity.
Fellows can also use this time to gain additional clinical exposure. The program director can help arrange rotations with allied fields, such as interventional pain, radiation oncology, physical medicine and rehabilitation, spiritual care or social work.