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Department of Pediatrics

Rotation: Long Term-Acute Care at HealthBridge Children’s Hospital

Master
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Rotation Description

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HealthBridge Children’s Hospital is a long-term acute care hospital that specializes in caring for children with complex healthcare needs. The fellow’s experience at HealthBridge will focus on learning more about children with medical complexity and strategies to provide holistic palliative care for this unique population of children and their families.

1. The fellow will spend one 4-week block rotation at HealthBridge Children’s Hospital.

2. Rotation coordinator: Dr. Courtney Toomey. Contact: CToomey@nhsltd.com.

3. Participate in daily bedside rounding with HealthBridge medical staff.

Clinical experience: Bedside teaching from HealthBridge physicians and IDT members.

Didactic experience: Teaching sessions from HealthBridge staff about patient care in LTACs and physical medicine and rehabilitation topics germane to pediatric palliative care.

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Fellow Responsibilities

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Daytime: Fellows will participate in daily patient care activities at HealthBridge under supervision of HealthBridge medical staff.

Call: No weekday overnight call. One weekend call per month with Texas Children's Hospital PACT service. Weekend calls include daytime rounding as well as overnight home call.

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Evaluation and Feedback

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1. Timely verbal feedback provided by faculty throughout rotation

2. Structured written evaluation of fellow by site director using American Academy of Hospice and Palliative Medicine evaluation tools at end of rotation

3. Fellow provides feedback to program director about rotation at end of rotation

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Goals and Objectives

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Goals and objectives based on Pediatric Hospice and Palliative Medicine Competencies, version 2.0

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Competency 1: Patient and Family Care

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The fellow should demonstrate compassionate, appropriate, and effective care based on existing evidence base in pediatric palliative medicine and aimed at maximizing the well-being and quality of life for patients with chronic, complex, and/or life-threatening conditions and their families. The fellow should provide care in collaboration with other subspecialists and within an interdisciplinary team.

Objectives: At the completion of this rotation, the palliative care fellow will be able to:

1. Assess the unique palliative care needs of a child who is a patient in a long-term care facility paying special attention to patients with complex medical conditions and multiple medical comorbidities.

2. Describe the illness trajectory of a patient in a long-term care facility and begin to analyze at what point palliative care is appropriate.

3. Compare and contrast the healthcare needs of children in acute care and long-term care settings.

4. Demonstrate ability to respond appropriately to suffering by addressing sources of medical, psychosocial, and spiritual distress, bearing with patient’s and family’s suffering and distress, and remaining a presence, as desired by patient and family.

5. Construct plans that balance a patient’s level of function and quality of life with concerns for longevity.

6. Demonstrate effective coordination of patient care, both from within an interdisciplinary palliative care team, with other palliative care providers including hospice teams, and in collaboration with colleagues outside of palliative care.

7. Balance a patient’s level of function and quality of life with concerns for longevity for patients and families.

A. Evaluate changes in functional status over time.
B. Evaluate quality of life over time.
C. Demonstrate expertise in maximizing patients’ level of function and quality of life over time.
D. Recognize the potential value of meaning making, creating a sense of legacy, and completing personal goals to patients and their family members.

8. Provide patient, family, caregiver, and staff education.

A. Educate families and caregivers in maintaining and improving level of function to maximize quality of care.
B. Explain palliative care services, recommendations, and latest developments to patients, families, and caregivers.
C. Provide education to various community resources involved in the care of the child and family.

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Competency 2: Medical Knowledge

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The fellow should demonstrate knowledge about established and evolving biomedical, clinical, population, and social -behavioral sciences relevant to the care of patients with life-threatening conditions and to their families, and relate this knowledge to the practice of palliative care in the long-term care setting.

Objectives: At the completion of this rotation, the palliative care fellow will be able to:

1. Describe the scope and practice of pediatric palliative care in a long-term care setting.

2. Identify unique features of medical care in long-term care settings and differing illness profiles including acute-on-chronic illnesses.

3. Contrast medical management of similar conditions in acute care settings with that in long-term care settings.

4. Apply pharmacologic and non-pharmacologic principles in treatment of symptoms common to pediatric palliative care, especially including pain, dyspnea, pruritus, nausea/vomiting, and constipation.

5. Describe the etiology, pathophysiology, diagnosis, and management of common neuropsychiatric disorders encountered in palliative care practice, such as depression, anxiety, delirium, seizures, and brain injury.

A. Recognize how to evaluate and treat common neuropsychiatric disorders.
B. Describe how to refer appropriately to neurological and mental health professionals.
C. Describe the indications, contraindications, pharmacology, appropriate prescribing practice, and side effects of common psychiatric medications.
D. Recognize the diagnostic criteria and management issues of brain death, persistent vegetative state,and minimally conscious state.

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Competency 3: Practice-Based Learning and Improvement

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The fellow should be able to investigate, evaluate, and continuously improve personal practices in caring for patients and families and appraise and assimilate scientific evidence relative to palliative care.

Objectives: At the completion of this rotation, the palliative care fellow will be able to:

1. Utilize self-evaluation and feedback from interdisciplinary team to appraise his/her performance and continually improve.

2. Integrate knowledge gained and begins to serve as educator for trainees and other healthcare professionals.

3. Integrate skills learned in the long-term care setting with previous knowledge to improve holistic care of children with complex, chronic medical conditions.

4. Identify knowledge gaps in the course of providing patient care and cultivate the habit of continuous inquiry to expand one’s knowledge base.

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Competency 4: Interpersonal and Communication Skills

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The fellow should be able to demonstrate interpersonal and communication skills that result in effective relationship building, information exchange, emotional support, shared decision making, and collaboration with patients, patients’ families, and professional associates.

Objectives: At the completion of this rotation, the palliative care fellow will be able to:

1. Utilize compassionate, effective communication skills to enhance interactions with patients and families, within the palliative care interdisciplinary team, and with other healthcare colleagues.

2. Utilize learned communication skills to effectively navigate interactions with patients and families including information sharing, discussing concept of palliative care, discussing advance care planning and resuscitation status, discussing goals of care, and discussing symptoms and suffering.

3. Demonstrate knowledge of the unique language of hospice and palliative medicine and effectively use this language in conversation.

4. Synthesize and effectively communicate patient information into the medical record.

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Competency 5: Professionalism

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The fellow should be able to demonstrate a commitment to carrying out professional responsibilities, awareness of his or her role in reducing suffering and enhancing quality of life, adherence to ethical principles, sensitivity to a diverse patient population, and appropriate self-reflection.

Objectives: At the completion of this rotation, the palliative care fellow will be able to:

1. Demonstrate care that shows respectful attention to age/developmental stage, gender, sexual orientation, culture, religion/spirituality, disability, and family interactions.

2. Demonstrate ability to balance the needs of patients, families, and team members with one’s own need for self-care.

3. Develop an understanding for the unique relationships that develop between patients and sta ff in long-term care facilities and its effect on patient care.

4. Recognize his/her own limits and ask for help when needed.

5. Demonstrate accountability and ownership in interactions with patients, families, and colleagues.

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Competency 6: Systems-Based Practice

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The fellow should be able to demonstrate an awareness of and responsiveness to the larger context and system of healthcare, including hospice and other community-based services for patients and families, and the ability to effectively call on system resources to provide high-quality care.

Objectives: At the completion of this rotation, the palliative care fellow will be able to:

1. Demonstrate care that is cost-effective and represents best practices.

A. Recognize relative costs of medications and other therapeutics.
B. Implement best evidence-based practices.
C. Identify similarities and differences among reimbursements for palliative medicine, hospice, hospital, home health, and long-term care.
D. Describe basic concepts and patterns of physician billing, coding, and reimbursement across settings.
E. Recognize the need to balance home nursing and hospice services for children with special healthcare needs.

2. Describe elements of the healthcare system relative to palliative care and how it fits within the model of long-term healthcare facilities.

3. Identify barriers and facilitators for successful transfer of patients between acute care and long -term care facilities and acute care facilities.

4. Collaborate effectively with colleagues spanning the palliative care continuum including hospitals, nursing homes, long-term care facilities, and hospice agencies.