Primary Palliative Care Clinic Pilot Project demonstrates benefits of a nurse practitioner-directed clinic providing primary and palliative care

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1 BRIEF REPORT Primary Palliative Care Clinic Pilot Project demonstrates benefits of a nurse practitioner-directed clinic providing primary and palliative care Darrell Owens, DNP, ARNP (Attending Nurse Practitioner and Director) 1,KerryEby,MD (Attending Physician) 2, Sean Burson, MSN, ARNP (Attending Nurse Practitioner) 3,MeghanGreen,DNP, ARNP (Attending Nurse Practitioner) 4,WendyMcGoodwin,MD (Attending Physician) 5,&MargaretIsaac,MD (Attending Physician) 5 1 Outpatient Palliative Care Services, Harborview Medical Center, Seattle, Washington 2 Hospital Medicine and Palliative Care Service, Overlake Hospital, Bellevue, Washington 3 Providence Health System, Primary Care Clinics, Mukilteo, Washington 4 Palliative Care Service, Virginia Mason Medical Center, Seattle, Washington 5 Inpatient Palliative Care Consult Service, Harborview Medical Center, Seattle, Washington Keywords Primary care; palliative care; nurse-managed clinics; nurse practitioners. Correspondence Darrell Owens, DNP, ARNP, Palliative Care Service, Harborview Medical Center, 325 Ninth Avenue, Box , Seattle, WA Tel: ; Fax: ; owensd@uw.edu Received: June 2010; accepted: November 2010 doi: /j x Abstract Purpose: The purpose of the Primary Palliative Care Pilot Project was to determine if patients with a life-limiting illness who receive their primary care and palliative care from a consistent provider via a nurse practitioner (NP)- founded and-directed Primary Palliative Care Clinic at a public hospital would have improved symptom management and decreased emergency department utilization over time. Data sources: All patients followed in the Harborview Primary Palliative Care Clinic from January to March Conclusions: The results of this project demonstrate that patients with a lifelimiting illness who receive their primary care and palliative care in an NPfounded and -directed Primary Palliative Care Clinic have decreased utilization of the emergency department, and some experience improvement in symptom assessment scores. Implications for practice: Palliative care providers and administrators should explore opportunities to expand outpatient palliative care clinics with an emphasis on primary care and continuity of care. NPs by experience and education are ideally suited to manage both primary and palliative care needs for people at the end of life. The majority of research related to care at the end of life continues to demonstrate that it is often substandard. Although many patients desire to die outside an institutional setting, the majority of Americans continue to die in healthcare facilities, with their pain and symptoms poorly managed (Goldsmith, Dietrich, Du, & Morrison, 2008; Kronman, Ash, Freund, Hanchate, & Emanuel, 2008; Tamir, Singer, & Schvartzman, 2007). Approximately 7% 9% of elders with cancer utilize an emergency department (ED) more than once in their last year of life, a setting that is considered less than ideal for the treatment of palliative care patients (Lawson, Burge, McIntyre, Field, & Maxwell, 2008). Research findings suggest that these issues could be improved through primary care and continuity of care (Burge, Lawson, &Johnston,2003;DeMaeseneer,DePrins,Gosset,& Heyerick, 2003; Gill, Mainous, & Nsereko, 2000; Ionescu-Ittu et al., 2007; Kronman et al., 2008). Unfortunately, the United States is reporting a critical shortage of primary care providers and overall poor continuity of care (Cardarelli, 2009). Continuity of care has been defined simply as the continuous relationship between a provider and a patient, as well as the coordination and sharing of information between providers (Gill et al., 2000; Ionescu-Ittu et al., 2007). It has long been considered a critical component 52 Journal of the American Academy of Nurse Practitioners 24 (2012) C 2011 The Author(s) Journal compilation C 2011 American Academy of Nurse Practitioners

2 D. Owens et al. Primary Palliative Care Clinic Pilot Project in the provision of primary care, has been associated with higher patient satisfaction, decreased ED utilization, and is reported to be of particular importance for vulnerable populations (Gill et al., 2000; Ionescu-Ittu et al., 2007; Nutting, Goodwin, Flocke, Zyzanski, & Stange, 2003). More recently, continuity of care has also been identified as a core value in the provision of palliative care (Michiels et al., 2007). The benefits of continuity of care for this patient population include increased patient and family satisfaction with end-of-life care, reduced ED utilization, increased compliance with treatment recommendations, fewer duplicate diagnostic tests, reduced healthcare costs, and, for some patients, reduced utilization of healthcare services (Kronman et al., 2008). The lack of primary care providers and continuity of care in the United States, especially for vulnerable populations, has become a significant healthcare concern. The lack of primary care providers with palliative care expertise and the lack of continuity of care for patients at the end of life are contributing to higher utilization of emergency services, poorer symptom control, and more institutional deaths (Kronman et al., 2008). The purpose of the Primary Palliative Care Pilot Project was to determine if patients with a life-limiting illness who receive their primary care and palliative care from a nurse practitioner (NP)-directed Primary Palliative Care Clinic (PPCC) at a public hospital, would have improved symptom management and decreased ED utilization. The environment Harborview Medical Center is a 415 bed academic medical center located in Seattle, Washington. It is owned by King County, and operated under a management contract with the University of Washington School of Medicine (University of Washington, 2009). Harborview is the safety-net hospital for the county, having provided over $140 million in charity care in The hospital s occupancy rate is approximately 98%, and despite performing over 224,000 annual clinic visits, the documented number of patients waiting to establish care with a primary provider exceeds 300 (University of Washington, 2009). The Palliative Care Service at Harborview was founded in 2003 by an NP. The inpatient consult service performs approximately 500 new consults and over 2000 followup visits annually. In 2006, in response to the need to improve access to palliative care for outpatients, the PPCC was launched. During the clinic s first year of operation, oncologists from the Hematology-Oncology Clinic (which operates concurrently with the PPCC) began to request that the palliative care NP assume responsibility for management of pain and bothersome symptoms for some of their complex patients. While caring for this group of patients, it was noted that many of them had no primary care provider or 24-hour access to a provider who knew their unique needs. Many of these patients frequently utilized the ED for pain and symptom management, and were at times admitted to the hospital for crises that could have been effectively managed in the outpatient setting by a palliative care specialist. Based on the identified need to provide patients with a life-limiting illness with 24-hour access to a palliative care specialist, in 2007 the PPCC was launched. The mission of the PPCC is to provide both primary care and palliative care to patients who have a life-limiting illness and no primary provider within the Harborview system, or the greater Seattle/King County community. Although initially developed for oncology patients, the clinic quickly began to receive referrals for patients with noncancer diagnoses, including dementia, heart disease, kidney disease, liver disease, and lung disease. Many of the patients served by the clinic also experience homelessness, mental illness, and active addictive disorders. In 2009, a formal relationship was established with a large regional kidney center to provide primary and consultative care to outpatients receiving hemodialysis. The PPCC receives referrals to assume the role of primary care provider from local hospice programs, skilled nursing facilities, community and university providers, and the King County Jail Health System for terminally ill inmates granted compassionate release for end-of-life care. Clinic care is provided three half-days per week, and through home and nursing home visits two additional days per week. Enrollment in a hospice program is not required, with only 30% of clinic patients enrolled in hospice. Continuity of care is provided to patients and families via 24-hour access to a primary care provider from the PPCC with a subspecialty certification in hospice and palliative care and who is familiar with their unique situation and needs. Methods Data collection Participants followed in the PPCC were assessed weekly during their program participation in January and February 2010, using a numeric symptom assessment scale via in-person appointments with their provider, or through telephone assessments conducted by a registered nurse from the PPCC. Nonidentifiable information from the weekly assessments was extrapolated from the electronic medical record and incorporated into a Microsoft Access database for analysis. 53

3 Primary Palliative Care Clinic Pilot Project D. Owens et al. Measures To facilitate multilevel modeling, we built data records at two levels: patient level and interview level. Patientlevel records included information (obtained from medical records) that did not change over time: gender, age in years at the time of study enrollment, primary lifelimiting diagnosis (cancer vs. other conditions), cognitive status (intact vs. impaired), and the number of visits made to the ED in calendar year From the ED visit information, we computed the patient s average visits per week during Interview-level records included all information with the potential to change between interviews: interview date and modality (in-person or telephone) and patients responses to interview questions asked at baseline and approximately once each week thereafter. Each interview included eight visual analogue scale items from the Edmonton Symptom Assessment Scale (ESAS; Bruera, Kuehn, Miller, Selmser, & Macmillan, 1991) measuring symptom burden. Patients rated pain, fatigue, nausea, depression, anxiety, drowsiness, appetite, and dyspnea, using a 0 (best possible) to 10 (worst possible) scale. The researchers omitted a ninth ESAS item (overall wellbeing) because of patient difficulty in understanding its meaning. At each interview, patients also indicated the number of visits they had made to the ED since the previous interview. For patients who could not be interviewed because of cognitive impairment, the interview-level record included only a rating for pain based on a Behavioral Pain Assessment Scale (BPAS; Ahlers et al., 2008) and the number of visits to the ED since the previous evaluation. The BPAS is a summed scale, based on a care provider s ratings of patient characteristics believed to be associated with pain (facial expression, relaxation or restlessness, muscle tone, vocalization, and consolability), each ranging from 0 to 2; as with the ESAS pain rating, the BPAS scale score ranges from 0 (best possible) to 10 (worst possible). Selection and description of participants The study received approval from the Institutional Review Board at the University of Washington. Participants for this study were those followed in the PPCC in January, February, and March To qualify for the study, patients and/or their surrogates underwent informed consent, and had to have participated in at least two different pain and symptom assessments during the study period. Participants had a variety of life-limiting diagnoses (cancer, end-stage kidney disease, dementia, chronic obstructive pulmonary disease, and heart failure); many also had a history of substance abuse, mental illness, and homelessness. Participants had been followed in the clinic for varying periods of time ranging from 2 weeks to 9 months. Results The sample A total of 49 patients contributed data to this pilot study. Table 1 summarizes the patients characteristics and symptoms. The sample was predominantly male, with primary diagnoses other than cancer, and averaged about 62 years of age. Just over one-third of the sample had some level of cognitive impairment; these persons were assessed for ED visits and pain, but for no other symptoms. About half of all patients had multiple visits to the ED during the year before enrollment in the study. Relative distress levels of the eight measured symptoms Over the pilot period, patients were assessed for symptoms an average of four times. At both baseline and over the course of study participation, the symptom causing the most distress, on average, was fatigue, followed by appetite disturbance. Similar rankings were obtained when symptoms were considered in terms of the percentage of patients who gave at least one rating over five; fatigue and appetite disturbance continued to dominate, and the only symptoms to exchange ordinal positions were pain and drowsiness (pain having slightly higher baseline and average levels, but with somewhat fewer patients rating it in the 6 10 range). Associations between symptoms and gender Table 2 shows patient characteristics and symptom averages separately for men and women. Women reported greater nausea and appetite disturbance at baseline than did men and were more likely than men to give at least one drowsiness rating greater than five over the course of the assessment period. In clustered regression models with weekly ratings clustered within patients and regressed on gender, drowsiness was the only outcome showing a gender effect with probability <.10. Women, on average, provided drowsiness ratings that were roughly 1.8 points higher than those given by men (p =.017). (This gender effect was not captured in the less sensitive Mann Whitney tests performed on patient averages.) Associations between symptoms and primary diagnosis (cancer vs. other conditions) Table 3 summarizes patient characteristics and symptom averages for patients with and without 54

4 D. Owens et al. Primary Palliative Care Clinic Pilot Project Table 1 Patient characteristics, ED use, and symptoms total sample, 49 patients Patient characteristics N (%) Cognitive status Intact 32(65.3) Impaired 17(34.7) Gender Male 31(63.3) Female 18(36.7) Primary life-limiting diagnosis Not cancer 28(57.1) Cancer 21(42.9) Mean (SD) Median (Range) Age 62.00(17.74) 60(25, 97) ED visits Total ED visits, (4.42) 1(0, 16) Mean ED visits/week, (.0848) Mean ED visits/week, (.1080) Symptom ratings Baseline levels Pain (n = 49) 3.59(3.11) 3(0, 10) Fatigue (n = 35) 5.49(3.16) 5(0, 10) Nausea (n = 35) 1.23(2.16) 0(0, 6) Depression (n = 33) 2.64(3.19) 1(0, 10) Anxiety (n = 34) 1.65(2.47) 0(0, 8) Drowsiness (n = 33) 3.42(3.57) 2(0, 10) Appetite (n = 34) 4.59(3.20) 5(0, 10) Dyspnea (n = 35) 1.57(2.63) 0(0, 8) Throughout study period a Pain 3.74(2.57) 3.33(0, 10) Fatigue 4.98(2.52) 5.67(0, 10) Nausea 1.31(1.58) 1(0, 6) Depression 2.70(2.74) 1.67(0, 8.67) Anxiety 1.94(2.50) 0.33(0, 8.67) Drowsiness 3.66(2.59) 3.5 (0, 9) Appetite 4.49(2.33) 4.58(0.6, 10) Dyspnea 1.75(2.24) 0.5(0, 7.75) High-distress ratings N (% b ) Pain 23(46.9) Fatigue 27(77.1) Nausea 9(25.7) Depression 14(42.4) Anxiety 9(26.5) Drowsiness 18(54.5) Appetite 21(61.8) Dyspnea 9(25.7) a Each patient s mean rating over all assessments was first computed. The values in the table represent the mean, SD, median, and range of these aggregated mean values. b Number of patients who gave at least one rating >5duringstudyparticipation, expressed as a percentage of the total number of patients who were assessed for the symptom. cancer. Cancer patients in the study were significantly less likely to suffer cognitive impairment than were other patients. As a result, cancer patients were more likely to be assessed for symptoms other than pain (3 4 times on average, compared with 0 1 times for patients with conditions other than cancer; p ranging from.001 to.003, depending upon the symptom assessed). Otherwise, cancer patients were not substantially different from patients with other conditions. Baseline ratings and average weekly ratings on all symptoms were similar for the two groups, and regression models using the weekly symptom ratings as outcomes revealed no symptoms that were strongly predicted (p <.10) by diagnosis. Associations between symptoms and other factors Estimates from clustered regression models with symptoms regressed on patient characteristics suggested two characteristics other than gender and diagnosis that were associated with differential symptom ratings. Patient age was strongly associated with reduced levels of pain distress, the average pain rating decreasing by 0.08 points with every added year of age (p <.001). Four other symptoms also had weaker negative associations with age: drowsiness (b = 0.05, p =.065), fatigue and anxiety (b = 0.05, p =.075), and depression (b = 0.06, p =.086). The number of visits to the ED in 2009 had strong positive associations with pain (each visit associated with a 0.25 increase in the pain rating, p =.004) and appetite disturbance (b = 0.18, p =.004), and less generalizable associations with depression (b = 0.18, p =.056) and fatigue (b = 0.11, p =.062). No other patient-level characteristics showed effects on any symptom with probability <.10. Assessment modality (in-person vs. telephone) had a weak association with ratings of appetite disturbance, with patients assessed by phone reporting appetite problem ratings about 1.3 points lower, than did those who responded in person (b = 1.32, p =.056). Change over time, and the moderating effects of other factors The mean number of ED visits per week decreased significantly between 2009 and the period assessed in 2010, from almost 0.07 visits per week in the earlier period to just over 0.04 visits per week after enrollment in the study (p =.001, based on Wilcoxon test). Multilevel models for the sample as a whole revealed no main effect of time on any symptoms. However, symptom trajectories varied substantially, depending upon patient characteristics. Gender had a reasonably strong moderating effect on the trajectories of three outcomes over time, with the moderating effect on appetite disturbance the strongest. In all three cases, men had a very slight increase in symptom ratings over time, while women had a decrease in symptoms. 55

5 Primary Palliative Care Clinic Pilot Project D. Owens et al. Table 2 Patient characteristics by gender Males (Total n = 31) Females (Total n = 18) Diff Patient characteristics N (%) N (%) p a Cognitive status Intact 22(71.0) 10(55.6) Impaired 9(29.0) 8(44.4) Primary diagnosis Not cancer 19(61.3) 9(50.0) Cancer 12(38.7) 9(50.0) Mean (SD) Median (Range) Mean (SD) Median (Range) Age 59.45(18.29) 56(25, 94) 66.39(16.32) 60(44, 97) ED visits in (4.94) 1(0, 16) 2.33(3.11) 1.5(0, 13) Symptom ratings, baseline Pain (n = 31,18) 3.45(3.14) 3(0, 9) 3.83(3.13) 3(0, 10) Fatigue (n = 23,12) 5.04(3.14) 5(0, 10) 6.33(3.14) 6.5(0, 10) Nausea (n = 23,12) 0.70(1.72) 0(0, 5) 2.25(2.60) 1(0, 6) Depression (n = 22,11) 2.50(3.25) 0(0, 10) 2.91(3.21) 2(0, 8) Anxiety (n = 23,11) 1.83(2.46) 0(0, 6) 1.27(2.57) 0(0, 8) Drowsiness (n = 22,11) 3.05(3.14) 2(0, 8) 4.18(4.38) 3(0, 10) Appetite (n = 23,11) 3.65(2.69) 5(0, 8) 6.55(3.42) 8(0, 10) Dyspnea (n = 23,12) 1.39(2.33) 0(0, 7) 1.92(3.20) 0(0, 8) Symptom ratings, throughout study period b Pain 3.68(2.62) 2.8 (0, 8.17) 3.84(2.55) (0, 10) Fatigue 4.65(2.73) 5.4 (0, 9) 5.60(2.01) 5.71 (2.67, 10) Nausea 1.24(1.69) 0.33 (0, 6) 1.44(1.42) 1.33 (0, 4) Depression 3.15(2.95) 3.27 (0, 8.67) 1.80(2.13) 1.40 (0, 7.25) Anxiety 2.41(2.69) 1.67 (0, 8.67) 0.94(1.73) 0 (0, 5.25) Drowsiness 3.30(2.71) 2.6 (0, 8) 4.37(2.28) 4.25 (0, 9) Appetite 4.17(2.08) 4.4 (0.67, 7.67) 5.16(2.77) 5.5 (0.6, 10) Dyspnea 1.77(2.05) 1 (0, 6.5) 1.70(2.67) 0 (0, 7.75) High-distress ratings N (% c ) N (% c ) Pain 14(45.2) 9(50.0) Fatigue 17(73.9) 10(83.3) Nausea 7(30.4) 2(16.7) Depression 11(50.0) 3(27.3) Anxiety 7(30.4) 2(18.2) Drowsiness 8(36.4) 10(90.9) Appetite 14(60.9) 7(63.6) Dyspnea 7(30.4) 2(16.7) a Tests for differences between male and female respondents were based on Fisher s exact test for dichotomous variables and the Mann Whitney Z-approximation for ordinal/continuous variables. b Each patient s mean rating over all assessments was first computed. The values in the table represent the mean, SD, median, and range of these aggregated mean values. c Number of patients who gave at least one rating >5 during study participation, expressed as a percentage of the total number of patients who were assessed for the symptom. Appetite disturbance (men s ratings increased, on average, by 0.02 points per day, whereas women s ratings decreased, on average, almost 0.12 points per day; p =.006). Fatigue (men s ratings increased by 0.01 points per day, and women s decreased by 0.07 points per day; p =.035). Nausea (men s ratings increased by 0.03 points per day, and women s decreased by almost 0.05 points per day; p =.063). Age moderated the effect of time on two outcomes. In both cases, increased age was associated with steeper declines in symptoms over time (or at the extremes of age with change from an increase to a decline over time). Anxiety (anxiety ratings for patients at the sample mean increased about points per day, younger patients ratings increasing more rapidly, and older patients ratings decreasing over time; p =.011). 56

6 D. Owens et al. Primary Palliative Care Clinic Pilot Project Table 3 Patient characteristics by diagnosis (cancer vs. other conditions) Not Cancer (Total n = 28) Cancer (Total n = 21) Diff Patient characteristics N (%) N (%) p a Cognitive status < Intact 12(42.9) 20(95.2) Impaired 16(57.1) 1(4.8) Mean (SD) Median (Range) Mean (SD) Median (Range) Age 64.96(19.71) 60.5(31, 97) 58.05(14.23) 59(25, 87) ED visits in (5.09) 1.5(0, 16) 3.00(3.38) 1(0, 13) Symptom ratings, baseline Pain (n = 28,21) 3.04(2.90) 2(0, 9) 4.33(3.29) 5(0, 10) Fatigue (n = 14,21) 5.64(2.76) 6(0, 9) 5.38(3.46) 5(0, 10) Nausea (n = 14,21) 0.71(1.82) 0(0, 5) 1.57(2.34) 0(0, 6) Depression (n = 13,20) 2.92(3.15) 2(0, 8) 2.45(3.28) 0.5 (0, 10) Anxiety (n = 14,20) 2.00(2.63) 0(0, 6) 1.40(2.39) 0(0, 8) Drowsiness (n = 13,20) 3.62(3.43) 4(0, 8) 3.30(3.74) 2(0, 10) Appetite (n = 14,20) 4.79(3.07) 5(0, 8) 4.45(3.36) 5(0, 10) Dyspnea (n = 14,21) 2.00(3.21) 0(0, 8) 1.29(2.19) 0(0, 6) Symptom ratings, throughout study period b Pain 3.55(2.59) 2.67(0, 8.17) 4.00(2.58) 4(0, 10) Fatigue 4.99(2.19) 5.88(0, 6.67) 4.97(2.76) 4.75(0, 10) Nausea 0.87(0.97) 0.5 (0, 2.5) 1.61(1.85) 1.4 (0, 6) Depression 3.33(2.85) 3.33(0, 8.67) 2.29(2.67) 1.17(0, 7.5) Anxiety 2.60(3.06) 1.04(0, 8.67) 1.47(1.96) 0 (0, 5.25) Drowsiness 3.79(2.69) 3.4 (0, 8) 3.57(2.59) 3.5 (0, 9) Appetite 4.36(1.79) 4.73(0.67, 6.40) 4.59(2.68) 3.92(0.6, 10) Dyspnea 2.09(2.51) 1.17(0, 7.75) 1.52(2.08) 0(0, 6) High-distress ratings N (%) N (%) Pain 11(39.3) 12(57.1) Fatigue 12(85.7) 15(71.4) Nausea 3(21.4) 6(28.6) Depression 7(53.8) 7(35.0) Anxiety 5(35.7) 4(20.0) Drowsiness 7(53.8) 11(55.0) Appetite 10(71.4) 11(55.0) Dyspnea 5(35.7) 4(19.0) a Tests for differences between patients with and without cancer were based on Fisher s exact test for dichotomous variables and the Mann Whitney Z-approximation for ordinal/continuous variables. b Each patient s mean rating over all assessments was first computed. The values in the table represent the mean, SD, median, and range of these aggregated mean values. Fatigue (fatigue ratings for patients at the sample mean decreased about points per day, with younger patients ratings decreasingly less rapidly [or even increasing], and older patients ratings decreasing more rapidly). ED visits in 2009 had a slight moderating effect on the trajectory of anxiety ratings over time. Patients with no visits reported slightly decreasing anxiety over time, whereas even one visit was associated with increasing anxiety over time, with each additional ED visit steepening the upward trajectory. No other patient-level factors moderated the effect of time on symptoms with probability <.10. Conclusions Our pilot project has identified that an NP-directed outpatient PPCC can reduce ED utilization at the end of life. The project also identified, albeit to a lesser extent, that this type of clinic can improve symptom management as measured by serial assessments using a numeric symptom assessment scale. The results of this pilot project are consistent with prior studies on primary 57

7 Primary Palliative Care Clinic Pilot Project D. Owens et al. care and continuity of care at it relates to decreased ED utilization. The lack of consistent improvement in symptom assessment scores over time, while unclear, is likely multifactorial. Although not a specific measurement of the study, clinic providers reported concern that given the relatively short duration of the study, patient/family misunderstanding of the particular scale utilized led to inconsistencies in symptom reporting that did not reflect true symptom scores, but rather adjustment to the scales used. Additionally, many of the younger patients had histories of past or active substance abuse, with associated patient fear that an improvement in symptom score could result in a decrease in opioids prescribed (and perhaps explains some of the age association with reduced levels of pain). Finally, lack of aggressive management of symptoms especially nonpain symptoms by providers over the relatively short duration of the study may be responsible for less symptom improvement than anticipated. The high utilization of healthcare services by people at the end of life has created a need for early and improved access to outpatient palliative care. NPs by experience and education are ideally suited to manage both primary and palliative care needs for people at the end of life. The majority of palliative care programs in the United States focus on inpatient hospital services directed by physicians. The reduction of ED utilization and improved symptom management outside a hospital setting can improve quality of life and quality of death. Our pilot project findings indicate that further research and exploration of the development and funding of outpatient PCCs is needed to improve early access to palliative care. Our study was a pilot project reviewing the medical records for a small number of patients followed in our clinic for a short period of time. As a pilot project, there was no control group for comparison; however, given the population under study identification of a control group would present challenge. Future studies, including our own, will need to include larger numbers of patients followed for longer periods of time. Finally, future studies should analyze symptom assessment for both cognitively intact and cognitively impaired patients separately especially given that different assessment instruments are utilized. References Ahlers, S. J., van Gulik, L., van der Veen, A. M., van Dongen, H. P., Bruins, P., Belitser, S. V.,... Knibbe, C. A. (2008). Comparison of different pain scoring systems in critically ill patients in a general ICU. Critical Care Medicine, 12(1), R15: 1 8. Bruera, E., Kuehn, N., Miller, M. J., Selmser, P., & Macmillan, K. (1991). The Edmonton Symptom Assessment System (ESAS): A simple method for the assessment of palliative care patients. Journal of Palliative Care, 7(2), 6 9. Burge, F., Lawson, B., & Johnston, G. (2003). Family physician continuity of care and emergency department use in end-of-life cancer care. Medical Care, 41(8), Cardarelli, R. (2009). The primary care workforce: A critical element in mending the U.S. healthcare system. Osteopathic Medicine and Primary Care, 3(11), 1 2. De Maeseneer, J. M., De Prins, L., Gosset, C., & Heyerick, J. (2003). Provider continuity in family medicine: Does it make a difference for total healthcare costs? Annals of Family Medicine, 1, Gill, J. M., Mainous, A. G., & Nsereko, M. (2000). The effect of continuity of care on emergency department utilization. Archives of Family Medicine, 9, Goldsmith, B., Dietrich, J., Du, Q., & Morrison, R. S. (2008). Variability in access to hospital palliative care in the United States. Journal of Palliative Medicine, 11, Ionescu-Ittu, R., McCusker, J., Ciampi, A., Vadelooncoeur, A., Roberge, D., Larouche, D., & Pineault, R. (2007). Continuity of primary care and emergency department utilization among elderly people. Canadian Medical Association Journal, 177(11), Kronman, A. C., Ash, A. S., Freund, K. M., Hanchate, A., & Emanuel, E. J. (2008). Can primary care visits reduce hospital utilization among Medicare beneficiaries at the end of life? Journal of General Internal Medicine, 23(9), Lawson, B. J., Burge, F. I., McIntyre, P., Field, S., & Maxwell, D. (2008). Palliative care patients in the emergency department. Journal of Palliative Medicine, 24(4), Michiels, E., Deschepper, R., Van Der Kelen, G., Berhheim, J. L., Mortier, F., Stichele, R. S.,... Deliens, L. (2007). The role of general practitioners at the end of life: A qualitative study of terminally ill patients and their next of kin. Journal of Palliative Medicine, 21, Nutting, P., Goodwin, M. A., Flocke, S. A., Zyzanski, S. J., & Stange, K. C. (2003). Continuity of primary care: To whom does it matter and when? Annals of Family Medicine, 1, Tamir, O., Singer, Y., & Schvartzman, P. (2007). Taking care of terminally ill patients at home, the economic perspective revisited. Journal of Palliative Medicine, 21, University of Washington. (2009). About Harborview Medical Center. Retrieved November 16, 2010, from 58