Working at the Top of Your License to Improve Community Based Care
On June 16, 2022, Honoring Choices MA, Hospice and Palliative Care Federation of MA, JSI’s Southeast and Central MA Palliative Care Workgroup and Norwell VNA & Hospice sponsored the first of its kind virtual panel discussion and call to action- Elevating the Role of Community Palliative Care Clinicians in Advanced Care Planning and Serious Illness Conversations webinar. We are so grateful for the participation of our audience: Community-based Advanced Practice Registered Nurses (APPR), Registered Nurses (RN), Social Workers (SW), Conversation Nurse, Administrators, and diverse care team members.
Our wholehearted thanks to our dynamic panelists for sharing their insights and expertise:
Nicole DePace, MS, APRN, GNP-BC, ACHPN, Director Advanced Illness Management Programs, Palliative Care Nurse Practitioner, NVNA &Hospice;
Holly Cristofaro, LICSW, APHSW-C, Palliative Care Social Worker, Norwell VNA and Hospice;
Kathryn Barzilai, GNP-BC, ACHPN, Nurse Practitioner, Community Palliative Care Team, Baystate Medical Center;
Kendra Botelho RN, BSN, CHPN , Conversation Nurse for Supportive Care Services, Southcoast Health.
The panelists shared innovative interdisciplinary team based models that empower APRN, RN, SW and Conversation Nurses to work at the top of their license and skill set to engage adults in effective planning conversations. They noted the opportunities and benefits of community based care, which can improve patient outcomes, prevent unnecessary hospital visits, lower costs and improve workforce retention. We discussed ways to remove barriers and build inclusive local care teams to deliver essential community based care.
We proposed four recommendations to upgrade protocols and support the interdisciplinary care team model. Attendees VOTED UNANIMOUSLY to adopt the following:
1. Update institutional and regulatory protocols to allow APRN, RN, LICSW professionals to engage in serious illness planning conversations including MOLST/POLST forms, to the full extent of their license and skill set.
2. Provide equal access to professional training to support the APRN, RN and LICSW licensure and skill set, regarding care planning and serious illness care conversations, SDOH assessments and trauma informed care.
3. Direct resources to community-based care to support diverse populations, which include linguistically and culturally appropriate documents and community based interpreter services.
4. Build more inclusive care teams to help rectify health inequalities where clinicians and care teams working within a medical setting will intentionally include APRN, RN LICSW and other local professionals from outside the setting to help improve timely, equitable care transitions.
Call to Action. We ask all Administrators, Clinicians and Care Teams to take action as follows:
• Review and update their institutional and state regulatory protocols to ensure APRN, RN and SW are working at the top their license, and support access to training and community resources
• Take steps to build more inclusive local care teams to help rectify health inequities
We are just getting started to work together to upgrade protocols and drive community resources to support the interdisciplinary team based models of care. Please send your feedback and further recommendations to Ellen DiPaola, Honoring Choices MA, edipaola@honoringchoicesmass.com
Special thanks to Honoring Choices Partners Ariadne Labs and The Conversation Project. We are working together to offer care teams members a packet of tool and conversations guides to help engage adults in seamless Conversations from simple to serious illness.
Who’s Your Agent? Program & Tool Kits; Getting Started and Next Steps, Honoring Choices MA;
Serious Illness Conversation Guide, Ariadne Labs;
What Matter to Me Workbook, Ariadne Labs and The Conversation Project.
Recommended Articles
1. C-TAC: “3 Reasons Why Palliative Care Belongs in the Community”; new study. Link
2. “The Conversations Nurse Model. An Innovation to Increase Palliative Care Capacity”. Link