University of California San Diego Health System

The University of California San Diego (UCSD) Health System, in collaboration with the Institute for Palliative Medicine at San Diego Hospice, developed and implemented a state-of-the-science and state-of-the-art Palliative Care program at UC San Diego Moores Cancer Center. Based on its success, UCSD recently expanded the program throughout its hospital system.

From the ground-up, the detailed design of the service is quite striking. Launched at the UC San Diego Moores Cancer Center in 2005, the Doris A. Howell Service was named in honor of the pediatric hematologist and oncologist who was former Chair of Family Medicine and now is a UCSD professor emerita and founder of San Diego Hospice. Howell, a physician role-model, teaches the value of compassionate and comprehensive care, including attention to control of symptoms and end-of-life care.

Matthew Loscalzo and Dr. Charles von Gunten were the principal architects of this innovative team-based consultation service, which aims to expand the concept of palliative care to include the full trajectory of cancer from diagnosis through survivorship or death. With a focus beyond end-of-life care, the service provides compassionate expertise for complex illness from the date of diagnosis to any cancer patient in need of symptom control or clarification of goals of care.

The Howell Service emphasizes a team approach to care and incorporates aspects of the hospice movement as originally conceived by Dame Cicely Saunders in the 1950s and 1960s, together with contemporary thinking about interdisciplinary palliative care. The team at the UC San Diego Moores Cancer Center evolved to consist of:

• an attending palliative care-trained physician (Dr. William Mitchell)
• a nurse practitioner with prescribing privileges (Heather Herman, NP)
• a prescribing pharmacist with expertise in pain management (Rabia Atayee-Samady, PharmD)
• a social worker with extensive experience in hospice care (Kathryn Thornberry, LCSW)

On the executive side, the team includes a service director, medical director, and administrative assistant.

Loscalzo and von Gunten emphasized in a recent paper that “[a] blended expertise creates a therapeutic synergy driven by that member of the team who can best influence therapeutic outcomes at any point in time.” Expanding on this method, Thornberry said “[t]he lines between the disciplines are more blurred, and our individualized approach is more about who on the team is the best person to meet the needs of the patient and family.”

The current Howell Service Director is Wayne Bardwell, PhD, MBA. Bardwell is a clinical psychologist with expertise in non-pharmacological interventions for management of pain and other symptoms. In collaboration with Medical Center management and von Gunten, Bardwell applied for and received a planning grant and a subsequent implementation grant in 2009 from the California HealthCare Foundation to expand palliative care from the cancer center throughout the UCSD inpatient facilities. To do so, UCSD formed a palliative care task force, involving various representatives throughout the medical center.

In 2009, Bardwell launched a 6-month palliative care fellowship program for nurse practitioners. The goal of this program was increase general expertise in palliative medicine among hospital and clinic NPs. Julia Cain was the inaugural fellow; at the completion of her fellowship she assumed the Howell Service NP position at UCSD Hillcrest hospital, joining Dr. Giovanni Elia, the attending physician.

The humanistic aims of the Howell Service expressly intersect issues of efficiency and cost. Dr. Mark Wallace, who also helped conceive the program in its earliest stages and is currently medical director of UCSD’s Pain Management Program, explicitly links the two. He notes the key questions: “Are we making our patients better?” and “Are we improving their quality of life?” have a cost-saving component: “Are we saving money by decreasing the number of days that patients spend in the hospital?”

The Howell Service is currently implementing a detailed data management system to track costs and patient outcomes. Tracking this data will aid in building a business case for palliative care and will generate efficient methods to gauge staffing level needs parallel to growth in patient volumes.