How to Plan for Your Program in Periods of Uncertainty

Many palliative care program leaders have needed to change plans during the COVID-19 pandemic. Forward planning can increase the odds of coming out of the other side of this pandemic with a sustainable program and team.

After the first surge, we heard from Donna W. Stevens, program director of Lehigh Valley Network’s OACIS/Palliative Medicine Program, who shared how she and her team leaned in to the opportunity to re-plan. During our conversation, available to watch on-demand (and below), we learned about how Donna’s team worked collaboratively with organizational stakeholders to re-plan, and ultimately, expand their practice to better support the changing needs of her health system. She also shared principles that her team used to approach leadership, during a time when financial resources were unusually limited.

In this blog post, we outline key takeaways from our first conversation and share updates that Donna recently provided (as her team responds to the second surge). We hope that her experience helps with planning for your program during this difficult time.

The dialogue from the following video has been included beneath it. Please note that the written form has been edited and synthesized for easier reading, with Donna's approval.

Donna Stevens (DS): I am glad to be here with you. I have been a palliative care administrator for fourteen years at Lehigh Valley Health Network, which has five hospitals and is located in Northeast Pennsylvania. We have a fully-integrated palliative care continuum, with a home-based team. I am part of a dyad leadership team with my clinical partner, Dr. Jennifer Allen.

DS: Our palliative care team decided that we were going to lean in to the uncertainty and figure out how we could support the effort, and what we could do quickly. We thought through how to identify and champion others’ goals, to demonstrate that we were part of the solution. We relied on guiding principles, such as ‘while supporting our organization, how can we also support and protect our team?’

We came up with different paths, since life was different one day from the next, and looked for new stakeholders that could benefit from our services. We responded to high demand in the emergency department (ED) with our inpatient team, and assisted with earlier goals of care discussions and advance care planning among our community dwelling patients, especially those at particularly high risk.

Specifically, we:

• Met with senior clinical leaders who outlined the crisis points within the network (ED and ICU)
• Met with our team to assess bandwidth and willingness to be reassigned
• Identified possible reassignments of our staff with ICU experience
• Reviewed reassignment implications to other staff covering patients
• Extended our inpatient team to the ED via consultations, vs. embedded
• Started recruitment to fill role of ED palliative care
• Communicated frequently with senior leaders from the ICU and ED regarding plans and updates

DS: Yes, many things do not turn out like you think they're going to. We had some turnover on our team once we shifted resources to the ED. We had to reduce our staff in the ED and manage the work differently. Despite our attempts to pivot to telemedicine, much of our very vulnerable patient population had difficulty with the technology, both with respect to access to devices and understanding how to use them. (This led us to apply for a grant, with the goal of helping our patients attain the technology to ultimately improve engagement with health care.)

DS: We focused on identifying our major stakeholders and the areas most in need of palliative care; what resources we needed in order to respond; and determining what our impact could be and if it would be realized quickly.

The outcome was threefold: our budgets were reapproved for the next year; we secured new resources along the way, to enable us to meet greater need; and we developed new partnerships and relationships that have helped us gain visibility and political capital.

Last month, we checked in with Donna to see how her team is doing, as cases were spiking in her area. Below is a summary of that conversation:

DS: Things have changed by virtue of where we are now with COVID. It's just a nightmare – cases in Pennsylvania are higher than ever before. We’re looking at what we can do and how to address it. One of the things that was different during the initial surge was that we had some bandwidth, as we had hired new staff and their census had not been ramped up yet. We were able to allocate people differently, which is how we helped in the ED. This time around, we are going into the second surge with no spare bandwidth.

We are experiencing a tremendous burden on staff on the inpatient side – we are at 30% higher patient volume than in the first surge, and are anticipating four times that going forward. Now we’re looking at how we are going to reallocate our resources when we reach crisis standards of care.

DS: Right now, the ED is one crisis point. We have allocated the inpatient team to be more available for consults there. We’re trying to bridge that need without having to embed a person full time. The other crisis point is in the ICU, because the unit is overwhelmed, and there is less staff due to increased quarantine, as more people are getting sick within the community. The more the pandemic escalates, the more our clinical staff are affected – not only at work, but at home as well.

Due to limited staffing, the network is re-deploying outpatient clinicians for inpatient work and pivoting to more telehealth – even though telehealth is not always our best option due to patient preferences and access. Many of our patients do not have access to technology or WiFi, or the understanding to adopt it.

DS: That’s a great question, as we can't do any of this without each individual staff person’s support. We would never reassign someone if they are opposed, as our top priority is staff retention – so, it's all with their endorsement.

My clinical partner and I are very open with our team about where we are, where the needs are, and what we perceive the benefits to be, to help them to understand. We feel that the more transparent and communicative we are, the more the team understands where we are coming from. Ultimately, you need your team’s support – especially in crisis times. You never want to implement something that goes against what the team feels they can accommodate.

DS: One thing that is occupying a fair amount of attention is safety in the home, since community spread is now the dominant mode of COVID-19 transmission. For each visit, team members are not only encountering their patient, but also their families and friends, and others who may be stopping by (e.g., plumber).

Also, our patients have limited access to both their family and paid caregivers, who are getting sick themselves with COVID, and being quarantined. This is a significant stressor on our patients, as they are left alone in their homes, when they normally have 24-hour care. Many cannot care for themselves, so they end up in the ED and then hospitalized, which is dangerous for the patients and worsens the current burden in the ED.

We’re doing everything we can to mitigate this situation. For instance, we’re trying to limit ED visits to “what’s needed” – if patients can have certain interventions done in the home, we advocate for that. And we are attempting to partner with healthy caregivers to give them the support they need in the home.

We’re also considering how to ease transitions for patients during this time. For instance, for patients transitioning to nursing homes, we are considering performing COVID tests. We are ultimately trying to utilize the skills and tools we have to be able to make life easier for people in the home. The more we can keep our patients out of the hospital, and well-cared-for as a clinical practice, there's no need to seek hospital care, as we can coordinate it ourselves.

DS: We are reaching max capacity, and do not anticipate the surge to peak until mid-January. We are trying to figure out if we will be putting up tent-beds, or how much of our new ED will be reallocated to COVID. Space is one thing, but staff capacity is more of an issue, as described earlier.

DS: Our leaders have said, “You never waste a good pandemic”. It is important to understand that your work is going to be noticed at this time specifically – if you're really going to where the crisis points are and making tangible impacts, it will reap benefits going forward. I consider it an investment – we received all kinds of relational and political gains from the first surge. And now, when trying to determine the needs of the whole health system, versus just our team, we are asking ourselves how we can make an impact and have it be sustainable for us as well. It is about combining those goals.

But in terms of advice, it is as simple as when you first developed your palliative care program. You do an assessment to determine what your stakeholders need. With needs changing as rapidly as they are right now, you need to stay attuned to this and repeat the needs assessment frequently. Also, pay attention to who is most in need, and what the issues are that palliative care can address. I’m hard pressed to identify any issue that we don't have some impact on – whether it's cost, quality, length of stay, etc. It’s about all the important things we can do to help patients, families, and our colleagues.