The Mount Sinai Health System Palliative Care Consult Service (5 months)
Established in 1996 with a $250,000 grant from the New York United Hospital Fund - Hospital Palliative Care Initiative, the Hertzberg Palliative Care Institute currently supports a staff of 40 individuals with a total annual operating budget of over 8 million dollars. The Institute’s clinical, teaching, and research programs are supported by the hospital, the Departments of Geriatrics and Medicine, clinical billing, federal and foundation grants, and philanthropy. Dr. Meier serves as the Director of the Institute along with her Co-Directors: R. Sean Morrison, MD, Director of Research; Emily Chai, MD, Chief of Medical Services; and Gabrielle Goldberg, MD, Director of Education.
The palliative care clinical program on average sees 110 new patients per month and saw almost 1300 patients in 2008. Over 60% of these patients are non-white. The team is involved in more than 25% of all deaths that occur at Mount Sinai Hospital. Thirty percent of palliative care service patients have a primary diagnosis of cancer. Moreover, cancer is the leading cause of death for all adult patients at Mount Sinai Hospital (62% of all deaths). The primary diagnoses of the remaining palliative care service patients are distributed evenly between heart disease; stroke/coma; dementia; end-stage lung, liver, and renal disease; and AIDS.
The interdisciplinary nature of the palliative care team is a fundamental characteristic of the discipline. The broad range of needs of patients and families as well as the intensity of the demands on health professionals require a team of professionals with complementary, but different, skill sets. The consult service consists of a staff of attending physicians, advance practice nurses, licensed massage therapists, a social worker and a chaplain. The team is also made up of fellows (geriatrics, palliative medicine, oncology), residents (including the disciplines of medicine, psychiatry, and neurology) and medical students. Involvement from pharmacy, psychiatry, and rehabilitation medicine occurs on an as needed consultative basis. All palliative care faculty and interdisciplinary team members teach interdisciplinary care by role modeling and by participating in the daily interdisciplinary rounds.
James J. Peters VAMC Palliative Care Rotation (2 months)
The James J. Peters VA Medical Center, located in the Bronx, is a Icahn School of Medicine affiliate and the site of one of six VA interprofessional fellowship programs in palliative care across the nation. This rotation will allow Mount Sinai fellows to train alongside palliative care fellows from other disciplines as well as to see how the provision of palliative care differs in a single payer system such as the VA. The palliative care service at the VA consists of three parts: the Supportive Care Unit, the Inpatient Consult Service, and the Outpatient Clinic.
The Supportive Care Unit is located in the long-term care facility on the grounds of the James J. Peters VAMC. The Unit is a dedicated hospice unit caring for patients with advanced, life-threatening illnesses who meet hospice criteria. Fellows will take on the primary care of these patients, thus giving them an opportunity to practice in both an inpatient hospice setting and a long-term care setting. The Inpatient Consult Service will afford trainees the opportunity to see patients in consultation from the acute medical/surgical wards, the ICU, and the spinal cord unit of the Medical Center. The Outpatient Clinic occurs one afternoon a week and will allow the fellows to see how outpatient pain and symptom management and care coordination occurs within the VA system.
The Mount Sinai Visiting Doctors Program (1 month)
The Visiting Doctors rotation at The Mount Sinai Hospital is one of two experiences the palliatibutve medicine fellows have in caring for homebound patients. This program serves frail, chronically ill, and homebound patients throughout Manhattan. It is recognized as one of the leading teaching programs for home medical care in the nation. Trainees will learn about family and patient needs assessment in the home, the nature and availability of funded and unfunded support services in homecare settings, and the experience of living with and caring for serious illness outside of healthcare institutions. While some of these patients are concurrently enrolled in a hospice program, the majority are not. This is what makes this experience with homebound patients fundamentally different from the rotation with the Visiting Nurse Service of New York.
Visiting Nurse Service of New York Home Hospice Care (1 month)
Since its founding in 1893, the Visiting Nurse Service of New York (VNSNY) has been a vital part of New York’s health system and public health infrastructure, delivering care to New Yorkers of all ages and walks of life, including those who are underinsured or lack the ability to pay for services. The mission of VNS is to promote the health and well-being of patients and families by providing high-quality, cost-effective health care in the home and community, to be a leader in the development of innovative services that enable people to function as independently as possible in their community, to help shape health care policies that support beneficial home- and community-based services, and to continue its tradition of charitable and compassionate care.
The Visiting Nurse Service of New York Hospice Care Program provides care for patients living throughout New York City with all types of illnesses, including cerebrovascular disease, diabetes, chronic ulcers of the skin, congestive heart failure, hypertension, osteoarthritis, cancer, and AIDS.
Fellows rotating with VNS Hospice make visits to patients in their own home with physicians, nurses, social workers, clergy members (or some combination of these individuals) in four of the five boroughs of New York City. This enables the fellows to be exposed to a complex and rich mix of ethnic, cultural, socioeconomic, and religious diversity thus enabling them to understand how these factors play a role in the care of patients at the end of life. In addition, fellows spend time with the medical director and director of nursing to better understand policies and procedures related to the Medicare Hospice Benefit. VNS contracts with several inpatient hospice facilities throughout the city, thus allowing fellows to learn how palliative medicine is practiced in inpatient hospice settings.
Calvary Hospital (1 month)
Calvary Hospital is the only fully accredited acute care specialty hospital in the United States devoted exclusively to providing palliative care to adult advanced cancer patients. It includes a 200-bed inpatient facility located in the Bronx, and incorporates a complete set of services providing outpatient care, case management, home care, bereavement, and family support services. Calvary is also a Medicare certified hospice provider, and palliative medicine fellows will spend time seeing patients who are on the hospice benefit both in the hospital and at home.
Patients are admitted to Calvary Hospital with symptoms of advanced cancer which often cannot be managed in other settings including uncontrolled pain, intractable vomiting, shortness of breath, complex wounds, uncontrolled seizures, hemorrhaging, pathological fractures, spinal cord compression, and severe mental status changes. The goal is to have each patient live as fully and comfortably as possible until life ends. To this end, patients may remain in the hospital for an extended period of time or are discharged with home hospice services provided by Calvary. Because of its complete model which provides care across multiple settings, Calvary earned a reputation for compassionate and skillful control of patients’ symptoms long before palliative and hospice care became well-known disciplines within the medical community. The foundations for this care are clinical competence, kindness, and the philosophy of non-abandonment. Calvary’s multidisciplinary model of care is dedicated to the relief of suffering which includes not only physical pain, but emotional, spiritual and psychological suffering as well. The family is considered an integral part of Calvary’s unit of care and is given exceptional attention throughout the patient’s illness.
Interventional Pain (2 weeks)
The Interventional Pain Service at Mount Sinai, run by the Department of Anesthesia, exposes fellows to pain management techniques including: acupuncture; injection procedures such as spinal, epidural, nerve root, joint, and botulinum toxin injections; and implanted devices such as stimulators and intrathecal pumps. This two-week experience will primarily be spent in the outpatient pain management practice. The purpose of this rotation is to have fellows learn when referral to an interventional pain specialist is appropriate and how these techniques can be used in the management of palliative care patients.
Pediatric Palliative Care (2 weeks)
Fellows’ pediatric palliative care experience will occur at the Elizabeth Seton Pediatric Center in Chelsea. The Center is committed to changing the lives of medically fragile children, one child at a time. Its programs are centered on children and their families, respecting individual cultural beliefs and practices. Each child admitted to the Center enters a Neighborhood where they receive team-based trans-disciplinary care, including medicine, nursing, social services, palliative care, mental health, rehabilitation, education, nutrition, child life/therapeutic activity, pastoral care and more.
Palliative care services are often a major component of the care of infants, children and adolescents who have complex medical, physical, developmental, and psychosocial needs. The Elizabeth Seton Pediatric Center places special emphasis on the needs of children, families and staff in anticipation of, and during, times of irreversible illness and death. The goal is to provide comfort from the disease process, while also addressing psychological, social and spiritual matters not only for the child, but also for the family and caregivers. Quality of life is improved through traditional and complementary treatments, including pain management, Reiki, mental health services and interfaith pastoral care.
Elective Rotation (2 weeks)
Each fellow has a two-week elective rotation. Fellows choose an elective which will improve their clinical skills or augment their knowledge in an area of care in which they desire more exposure. Recent activities by fellows have included: spending extra time with The Visiting Doctors Program, rotating with the adult heart failure service, spending time in the division of radiation oncology, and rotating with the neurology consult service. With sufficient planning, fellows may do rotations at other institutions in New York City as well as throughout the US.
Scholarly Activity Block (4 weeks)
All fellows spend at least four weeks dedicated to scholarly activity. Having this time during the clinical year allows fellows to integrate academic activities with their clinical duties and allows them to begin scholarly writings, such as review papers and textbook chapters. For fellows considering a research career or who will be completing a research track during their training at Mount Sinai, these research blocks allow them to begin collaborating with mentors throughout the medical center.
Outpatient Palliative Medicine Continuity Clinic (12 months)
The ambulatory rotation for palliative medicine fellows consists of a weekly four-hour session for a total of twelve months. This is meant to be a consultative palliative care clinic. The majority of patients are referred to the outpatient practice from the inpatient consult service, though patients may be referred directly from physicians throughout the medical center (including from oncology, neurosurgery, and anesthesia pain service). Fellows are assigned a panel of patients which is their primary responsibility. They are responsible for all activities relating to these patients (e.g. seeing patients in the outpatient setting; coordinating care with social work; communicating with physicians in other specialties; answering phone messages from patients, families, visiting nurses, and home health aides; prescription refills). Fellows write admission notes on their patients when admitted to Mount Sinai Hospital and contact the medical staff when patients are transitioned to other sites of care (e.g. hospitalized at another institution, transitioned to inpatient hospice, etc.).