Amber Moody & Kelly Corcoran

00:01 Hi. My name is Kelly Corcoran, and I'm the chief mission officer and the executive lead for our palliative care services here in rural Stevens county. And with me today is our palliative care nurse, Amber, would you like to introduce yourself?

00:17 Yeah. Hi. My name is Amber Moody. I'm the palliative care nurse here in Stevens county for two critical access hospitals.

00:25 Great. Thank you, Amber. So we are here today to talk about how our program of palliative care grew into a telehealth palliative care program. And first of all, I'll just kind of back the train up a little bit and just have a few statements of my sense of what was going on here and a vision of what I have. Rural America makes up at least 20% of the United States population, and here in Stevens county, which is very rural, 25% of those people are over the age of 65 and soon to be much larger than that because the next largest population is the 55 to 65 year olds. So given that rural community and given the age of the people that live in these communities, the risk factors for health disparities are huge. So it's not just geographic isolation and lower socioeconomic status, a higher rate of health risk behaviors, but it's traveling significant distances to treatment. And frankly, there's just not access to specialists and sometimes even primary care. And so physicians aren't so readily attracted to working and living in rural health, partially because the patient volume is low, but partially because of all of the other benefits, so to speak, that come with living in an urban area. So that's just a little bit of the background. And here in Stevens county, for years and years, there was an individual nurse who had a heart for palliative and hospice care, and she is the one who planted the seeds for a palliative care program here. She was very highly skilled, and yet she liked to work alone. And so after a while, the program grew into a much greater need. And so that is where we are today. And to begin with, I tried to reach out to anybody that was also interested in palliative care or was connected with the palliative care program in different ways. Chaplains, social workers, pharmacists, etcetera. And I spoke with them individually, and we spoke about what has been your role in palliative care? Do you have any specific training? What's your biggest challenge? In a perfect world, what would you like to see our ministries grow into here in Colville and Chewila? So it became pretty evident that there was a call for a healing process within relationships and to be able to understand where people were coming from in the care that they provided, which seemed to have taken place within silos, quite frankly. So there were some key areas that were brought forth from those conversations to nurture relationships, to develop policies, and to identify the scope of service between roles, to provide training for certification for nursing social workers in chaplaincy, to make sure that we're connected and being informed and supported by our Department of Health rural health initiative for palliative care resources and by CAPC to calendar meetings and IDT meetings and to purchase equipment. And the equipment was an evolution which Amber will speak to as well. And we're finally at a place of data collection, and Amber will speak to that as well. So, Amber, why don't you take it from here and talk about kind of your journey, as well as the needs and the evolution of our tools of charting and of data collection?

05:06 Absolutely. For me, it's really interesting. I was a med surg nurse here in this critical access hospital, and I knew the lone palliative care nurse and worked with her often and was working with her when, you know, the pandemic hit. And when the pandemic hit, bedside nursing got really hard and we really didn't get to spend as much time with our patients, and our patients were sicker and their families weren't able to come in, and there were all these new needs. And so in my nursing brain, I'm thinking, man, I don't know if I can do this. I don't know if I can be a floor nurse in a pandemic. And I'm thinking every day, how can I find a place to better suit my needs as a nurse that would fit with needs of this community? And then, like magic, the lone palliative care nurse is retiring. And I hear about it, and I apply for the position, and in applying for the position, they say, oh, hey, by the way, we're growing. We're going to be a group. We're going to be a team. We have a palliative care doctor, a palliative care social worker, a mission director, chaplains, and we're going to be a team that gets to treat patients not only at Mount Carmel, but at St. Joseph. And I interviewed, and I was lucky enough to be added to the team. And we've been at this a year. And for me, the transition has just been just been breathtaking to watch us grow. We've gone from a single nurse to a team of people who really work well together. We're interdisciplinary, not just multidisciplinary so we communicate well. We take each other's opinions, and we get to really serve our community. I'm really lucky in the fact that I get to be here with the patients every day, and I still get to be bedside when it's needed. We get to see patients with higher needs, and I get to bring my team in when I see that there's a need that we can't meet locally. So for me, that transition helped me find a place in nursing where my heart could be in it. I could spend more time with my patients. And instead of my patients having to leave the county and travel maybe 70 or 80 miles to talk about palliative care, we were bringing the team to them, maybe bedside, maybe over Zoom, maybe over conference calls, but we're bringing a specialty team to the patients in their rooms. Now, we've had some bumps doing that. We're in a very rural area, and Internet connection can be sparse. People's understanding of the Internet or access to the Internet itself may be sparse. And so along the way, you know, we've developed, we've gotten pretty fluent in maybe patching in a zoom conversation, a conference call via cell phone, and then we'll have an iPad hooked up, plus a couple practitioners, maybe the nurse in the chapel and bedside with the patient. And, you know, we've been able to meet the needs of those patients and family members by bringing them in from maybe the very northern part of our county, and maybe it's 70 miles away, or Australia, where their daughter hasn't seen them for six years, but now they're face to face, face on a Zoom call with their, say, their dad and their doctor. And so the really neat thing is we brought this technology in, and it's an older community, it's a conservative community, but we have this bedside connection as well as the technology. And so we've been able to still really bring a personal experience to these patients. And even if it's just over the phone, we've made some great connections that are just ongoing with the community. And I just. I'm so happy to be part of this team and part of where we've developed and specifically, you know, where we're developing, too. I look forward, which probably brings us into our biggest challenge of technology, I guess. But, you know, we started our consults. I would say our first consult was an ICU. We had one iPad and a smaller iPad. I don't know what generation it is, one iPad. That is the audio, that is the video. It is on a stand with an arm. And our very first telepaliative consult had three family members, a patient, a surgeon, a hospitalist, a chaplain, myself, and then an on Zoom palliative care physician and palliative care social worker. So we're getting all these people on this one iPad. You know, as the nurse in the room, you're moving the iPad around, getting each person's point of view. The daughter was so excited and got animated. She's moving things around and showing people the video, and people were excited. And fast forward to yesterday. We're using, you know, beautiful new equipment, a large screen so everyone can see. I think yesterday we had eight family members on a call, and they hadn't been together since 2015. We have a speaker and a microphone. So even if these patients are on BiPAP or a ventilator or something in the room is so loud because of isolation, we can still hear them, and they can still hear us. We have a team of people that have developed and thought of every aspect of technology that we can utilize and make it personal, and we've grown so much in that, and it's so exciting to bring that new machine into the room. And the patients maybe have heard about palliative care, maybe they haven't. But by now, the staff. Staff has heard about palliative care, and now they know who we are, and they're asking for us. And that is really, really exciting to me.

11:37 It is exciting, Amber, and I think it speaks to the training that you have received and that Chaplain Gretchen has received. My personal philosophy with rural health is, in being rural, our services should be just as exceptional as a hospital in the heart of Chicago. And so sending you to your palliative care certification world as well as the chaplain is really a gift. And I think it both professionalizes how you're viewed in the hospital, but also hones in on your skillset. So could you speak to maybe some specifics about that training?

12:29 Yeah, there's been two really great trainings that. That I've been able to go through. The first was the palliative care nurse certification through the Shirley Institute out of California. And I was able to join a twelve week online, basically a college credit type class set up where you have weekly homework and assignments, and you go through every body system and every scenario that you can think of. But instead of just going through a body system as a nurse, you're going through this. As a palliative care nurse, you change your mindset. You're caring for the whole patient. It's holistic. You have a team behind you. And so for me, being a nurse for 14 years, to be able to shift my brain, not just to, you know, I have meds to give. I have this, I have that, and, you know, I got to shift to, oh, this patient has family that can't come in. And now, how do you assess heart failure? And they have all these other needs, and they're rural, and maybe they're ready for hospice. And so it shifted your train of thought to just a very clinical diagnose, treat mindset to the bigger picture. And after that certification, I've used so many techniques that they taught me, then studied, and was able to take the national certification for certified palliative and hospice nurse. For me, again, it was just a big transition in mindset. You know, we dose the same medications, but we have different. A different mindset. We are wanting our patient comfortable, and if that's outside the box of the regular dose of medication, that's what the patient needs, that's okay. And, you know, we can get on cap c through the hospital, and we can indulge ourselves in videos and conferences and just really immerse yourself in the world of palliative care, because it is a specialty, its own place of, you know, divine, compassionate care for patients and their family. You know, and being able to bring our team in through telehealth, it benefits us as staff, too. These are trained specialists. These are people that have had years of experience in palliative care. And so to work with them, you want to be at that higher level. You want to work hard to certify, to know the most up to date things to do for your patient. And so the chaplain, Gretchen, and I are just blessed to be able to live rural, but jump into these huge trainings and national certifications and then bring it back to the patients in our county.

15:18 Right. Right. Thank you, Amber. And, you know, the other thing is the skill set is a skill set that can be learned. The language. It's a whole new dialect of language, so to speak, with palliative care, but it's also a relationship based care. And so the psychosocial dynamics of who we are as individuals, who our patients are as individuals, what we think is best, what the science says, what the family weighs in with, where is the patient in all this? What does the patient really want versus what is the patient agreeing to? There's all those relationship nuances, and the other piece of that is the ongoing relationship with the staff. And so that's not only boots on the ground, face to face, but it's charting. So, Amber, can you speak to your experiences of shifting relationship nuances with the physicians and with other nursing and, you know, the whole care team, but also how the ways and the methods that.

16:37 You chart have evolved with telehealth, it's definitely relationship based. You know, we work with a hospitalist at both hospitals, and to see these patients, we need an order to see these patients. And so we need either the physicians or the nurses to say, I know there's a palliative care team here, and this patient has needs that I think they can help with. That's been an evolving thought process because previously, if you put a referral in, you got a nurse that came, visited the patient and it kind of stopped there. Now we have pharmacists that are palliative trained. We have a physician, we have social workers, we have chaplains on board. And so trying to build the relationship with the people that are putting our orders in is huge. You have to know what you're offering them and then they have to know. And so you have to build relationships and be at the meetings and follow the patient census and be on the floor and speak with the nurses and say, I see that your patient has heart failure and a new lung tumor. Do you think they'd be good for palliative care? Because I do, and here's why. And so not just building the relationship, but educating. There's palliative care at a higher level, and it's now available here. And for me, it's really exciting to look through the computer and see orders that nurses are putting in or pharmacists are putting in, because that's never how it used to be. It used to only come from the physician. And now we've got people thinking and talking about, hey, we have palliative care here and they can help us with this. And so building those relationships and then having people know that we'll follow through has just been so important.

18:37 Absolutely. So I can't say enough of the skill set and the love that Amber brings to not just what she does, but how she does it. I mean, who she is informs how she provides her care. And it has certainly given permission to the physicians to enhance, I'm going to say, how they, their way of being with their patients. And it might seem, well, yeah, the physicians are with the patients anyway, but it truly is a different way of being. It's a different approach for physicians to come into evaluating a patient based on a relational scope and sequence of how this patient is in life. So there have been a couple tools that Amber has developed and that she's taken on from CAPC Amber, do you want to talk about the esas and your diagnostic tools?

19:41 Yeah. We had to find a way to get, to get a uniform way to identify who's a palliative care patient who might benefit from our services. And so we took to other palliative care programs, took to CAPC and we found screening tools that are really easy for a practitioner to look at, to assess their patient in a matter of seconds to see if they would be available for palliative care. The palliative care screening tool has been huge. It gives a list of diagnosis that the practitioner can look through, and then down at the bottom, it gives a list of psychosocial reasons why it would be appropriate for a palliative care team to be involved. And that's kind of the new mindset. And so it's really easy for practitioners to look down and if it's really a score of three or above, put in a palliative care order, and then there's ways that if patients are already admitted and I'm on the floor and I'm seeing these high diagnoses, but they don't have an order for palliative, I can go in and see them, I can do an Edmonton assessment and symptom scale and we can talk about their pain, their suffering, their stress, their anxiety, and we can score it. And if it's high, then we hope that we can help them. And being able to make that kind of a uniform process. And so we aren't missing patients. That has been a huge benefit. The other benefit is that we've been able to develop where we chart and how we chart. How do you find out that palliative care is involved in this patient? How do you find out that palliative care has seen this patient for the last six months? Months. So we worked with informatics. We built FYI flags that pop up and follow a patient through every providence admission. They say, this is a Providence Stevens county palliative care patient. For support, for goals of care, please call this number. And people are doing that. They're using that. They're calling us from the emergency room and they're saying this patient had a previous experience with palliative care. I don't know if they want admitted. I'm not sure where they want to go. Will you come see them? And so we go to the ER and we see them. Do they even need to be admitted? Maybe not. When we see patients and do our consults with them, we chart goals of care and advanced care planning templates that they helped us build, and they address things that are palliative, care specific. Is this patient suffering? What's their family dynamic? Do they have spiritual distress? Do they have symptoms that are physical that we can help? Do they have forms like pulse forms, advanced directives? And so when the hospital has put an order in and they know we're going to see a patient, they can look back, they can see all these things that we've covered in one format. They know where to find it. We also do charting with the IDT note, which I really like. We have our twice a week interdisciplinary team meetings where we have our whole team. I don't even know, Kelly, how many people are probably at those meetings a week? 15.

23:25 Oh, my goodness. Anywhere from seven or eight up to probably twelve, I think is the most folks, most. The greatest number of folks that I've seen on those calls.

23:34 So I love that. You know, we get input from this huge team. We discuss each patient that we're seeing for the week, and then we round back and we put a progress note in as an interdisciplinary team. And it mentions the pharmacist said this discharge planning, said this PTOT nutrition, and it's a twice a week summary of where this patient is and where we're going and what their hopes and goals are. And so developing those things in Epik, I think it's really special. I think it gives people really valuable information, and I think it gives them information that without a palliative care team, maybe we wouldn't ever get to, or maybe we wouldn't even know about that patient.

24:18 I so agree, and I'm so excited about that. And, you know, I think one of the blessings of this whole pandemic is that the online teams application has been able to enhance our rural communication, because the pharmacist may be at St. Joe's and we may be talking about a patient up at Mount Carla Carmel, and he or she can weigh in from where they are. The other piece is that in connecting with the tele social worker and the telephysician, they dial in, so to speak, from Spokane and from Olympia. So the IDT meetings are invaluable for two pieces, for, obviously, patient care, but also to gel as a team. And that is one thing that has been really powerful here in Stevens county, is that this team is cohesive. They're loving, they inform each other, they learn from each other. They know when somebody's in distress or struggling, you know, for whatever reason, and are able to provide that care and support to their teammates. The other piece is when our tele provider and our tele social worker chart, they also are informing PCP. And so the primary care physician has a heads up as to what is happening with this patient regarding their symptom management, their personal needs, and how our palliative care team is addressing those needs. Throughout this. For the past year, I guess I would say there have been a couple different checkpoints because we wanted to make sure that we were doing what we said we were doing. And so we have had two assessments. One has been sponsored through the Department of Health through RHAT And that was a community asset and gap analysis. And so several of us were called together, and we put our heads together and said, who ought to be on this call? Who are the community leaders that we need to reach out to? So we compiled a list and, again, were able to reach a number of people. Because of the pandemic, we didn't have to rely on scheduling a conference room, having food catered in. Can people make it? How do we reimburse their mileage, et cetera, et cetera. They could just sit in their office and tune in. And so that's what we did. And we had over 34 people weigh in on our community asset and gap analysis. And certainly there were a number of things that were called out, a number of things that were positive and awesome and exciting, and a number of obvious spaces and places where we can show up with some intention in our community to expand our palliative care services through education and awareness. And I think just as Amber has worked so hard and so diligently with the rest of our team to develop those relations inside the walls of our hospitals, so, too, you know, the next step is to take that outside the walls of our hospitals, and so to provide those that education, to nurture those relationships with other rural organizations that provide care. We have an institution here. It's also a not for profit institution called rural resources. And they provide for the social service aspects of folks in Stevens county who don't have access to food, who don't have access to consistent mental health support, who don't have access to getting in their car and getting their prescriptions filled. And so these are folks that we can connect with, and the community can take care of them. And so it's a whole, it's a deeper, broader, higher service line that we can create here in our rural communities, which is a blessing, and it's so very needed. So that's one piece and then the other assessment was, we did our own assessment. So about six months in, we created a swot analysis. And so the team came together. And again, it wasn't just our local team, but it included our telepsych and our telesocial worker and our telephysician. And we asked the questions, you know, what are we doing right? Where can we improve? What are the threats and what are the opportunities of what we're doing? And so what we're doing, right, is that having a team in which to drive resources from different disciplines and skill sets and educational backgrounds and experiences completely and totally enriches the services that we can provide for our patients and families, providers and caregivers. So with everyone involved, with intention, it's a huge gift to how we provide the care, not just what the care is that we're providing, but how we are providing the care. And another piece that we were able to call out is we were a little concerned that a teleconsult might seem impersonal and might seem distant, and would patients be able to relax and be real within these consults? And what we discovered is the distance provided a safety of anonymity. And so patients, I think, opened up even more to doctor van Deke and to Ed and to our nurses and chaplains and physicians with boots on the ground. So that was a real gift. And for patients, as Amber mentioned earlier, to be able to connect with the daughter in Australia, I mean, come on. Right? That's huge. And to talk about what's important to the patient, what she would prefer, all of those aspects of who she is as a human being, not just what's her disease and what can we do to fix the disease, but who the patient is as an individual and what might be the best way of supporting her in her life. So that's just a. Just a couple comments about our analysis and holding ourselves accountable as well. And Amber, I'm wondering if you could share a patient story that has really touched your heart.

31:27 Yeah, it's really fun to work in this community. I grew up in this community, and we're a small community, even though I serve two hospitals, oftentimes, the. These patients are my kids teacher. They were my high school softball coach. They taught drill team. They rodeoed. They grew up here as well. And so these patients are personal. It's members of my community as well. And initially, it really touched me that we would go in and help maybe young cancer diagnosed patients. And in this community, cancer to a patient is cancer to the community. You see fundraisers. You see flags hanging everywhere. You see their name or maybe their high school football number on the door. And being able to go into to these patients that have cancer and live in rural Stevens county where there are no specific cancer services, being able to bring palliative care to them and sit at their bedside and say, where are you at today? Are you having more pain than usual? There's a patient that will always stick with me that our community lost. But before we lost them, we got to work with them weekly as they were hospitalized in and out. And we got to sit down for really important conversations with this young family and say, I know nobody wants to plan for the day that you're not here, but what do you want that to look like? And although they had been battling cancer for three years, no one had asked them that question. And, you know, the chaplain and I sat there and we walked through eleven pages of an advance directive with her, and her family is learning about her. And they're having a discussion that without our team there, they never would have had. And that holds a really special place for me because if we didn't bring palliative care to them, they wouldn't have gotten it without leaving our area, traveling 70 or 80 miles and being admitted to a huge hospital that has more beds than our town has people. And so that was one of my first experiences where I thought, wow, look what we brought to that patient. And the more that we do that, the more feedback we get. We receive emails from family members who are also hospital employees in a pandemic. So, you know, that they're busy and they're stressed. And days after meeting, you know, with their family member who is seriously ill, they're sending emails. Thank you so much for taking the time to help us navigate this completely unknown situation. Maybe it's part of your protocol, but it was huge. It really clarified why he needs transfusions and what that future will look like. It helped us determine where we needed to access care. You guys were compassionate and helpful to our family. Just wanted us to know we appreciate all you do and everything you did for us. You know, the patients will often say, thank you so much when you're in the room, or the next day they'll say, thank you for bringing. And like you said, the computer screen. They'll motion to Doctor Greg on the computer screen, thank you for bringing the doctor here. But for families to sit down and write an email and say, thank you for that. I work for Providence and I didn't know that was available. That was amazing. And recently, at our even smaller hospital that we work at, we got a call from the hospitalist that said, hey, this patient's requesting palliative care. So I put an order in, and I thought, cool. Okay. So I get down there, and I recognize them, and our other patient is now a family member, and they're requesting palliative care for their family who's in the hospital, because six months ago, they had a great experience, and they felt heard. And for me, that was really validating. It was full circle. The patient is now the family member, and they're asking for superior care for their family member in the hospital. So those stories, those people that are part of our community that are having great experience because palliative care is involved. For me, I just. I'm just. Wow.

36:49 Yeah. It's overwhelming to think about it. When I think of our patients who are fragile and who are benefiting from palliative care, and some of the folks who are moving into hospice, people have to let go of. They have to give up so many things. And it's sort of the slow ebb towards everything I have been is gone. And with palliative care, that changes. That shifts to, I am still whole. I am still who I am. And so the legacy story that families carry with mom, with dad, with aunt or uncle or whoever, is about a fullness of life, as opposed to this slow ebb, to not being here anymore. And that's huge. That is huge. To shift the focus of that legacy story, that's one of the pearls that I have taken away from this is just that piece that the respect and the dignity and the compassion with which our palliative care services show up within these family systems. It's tremendous. The nuances of relationships that are healed, the opportunities for deepening understanding within families that occurs with palliative care. And, of course, it's as if the care is woven together into this beautiful tapestry that affects, again, not just the patient and the families, but affects the relationships within the caregivers themselves. So, Amber, do you have one other little pearl of wisdom before we close?

38:45 Yeah. Mine is so. Mine is so close to yours that people that live in this community have made a choice to be here, and they shouldn't have to give up quality healthcare because they want to live.

39:00 Right.

39:01 And so, in 2022, it's our duty to bring that care to patients. And I feel like. I feel like we nailed it. I feel like you have to bring the quality care, the compassion, the wraparound services to your patient where they're at. And it's a different level of care when you make the step to to do that.

39:29 I love that piece where they're at. Where they're at. Those are three very powerful words, Amber. If we say we're going to meet them, where they are, that's where we should be is where they are. So this kind of wraps up our little presentation here. Unless, Amber, if you have anything else you can think of to share that would be helpful for folks.

40:00 I just think that recognizing that our world is different now, the pandemic is winding down. But, you know, healthcare may be forever changed for people. And so having telepaliative care programs where you bring specialists to these patients and you help them navigate the really scary pieces of their future, I just think it is a blessing, and I'm just really excited to be part of it.

40:37 Well, thank you, Amber. And I am very excited that you are part of it as well. So thank you, everybody.