INDIANAPOLIS — A grant awarded to a multidisciplinary team of educators at George Washington University’s School of Medicine and Health Sciences has produced a new teaching tool for integrating palliative care into geriatric care, thereby harnessing the practices of both fields to smooth the transition from one to the next.

"The point is to integrate our approach to geriatric, which is a very medical model, with palliative care, which is much more transitional or dealing with loss, really client-centered," said Mary A. Corcoran, OT/L, PhD, FAOTA, professor and associate dean at the school, and member of the team that created the Geriatric Education Using a Palliative Care Framework training tool, which delivers training through online modules. The modules can be used in a variety of ways, such as in classrooms or in-services at facilities. They also can be combined with hands-on learning, Corcoran noted during an educational session on the GEPaC that she presented at the AOTA 2012 Annual Conference & Expo in April.

"Combining these two approaches recognizes that grieving is a response to all types of losses," Corcoran said. Occupational therapists "help people deal with losses all the time, help them pull together their adaptive responses to be able to go on."

Multidisciplinary approach

GEPaC, which has been under development since GWU received a grant from the U.S. Health Resources and Services Administration in 2010, offers five modules: Introduction to Geriatric Palliative Care, Person and Family Centered Care, Communication, Interdisciplinary Collaboration, and Multidimensional Aspects of Suffering. A sixth module, Quality of Life, is not yet available. Quality of Life will address not just physical, but psychological, social and spiritual aspects, Corcoran said. The modules can be accessed online at: gepaconline. nnepi.org.

"GEPaC works toward smoothing the transition among settings, which we can all see is very disjointed at this point," Corcoran said. Geriatric patients "get discharged from one place, go to another, get discharged from that place to another. People don’t talk to each other. It’s very frustrating for the client and it’s very frustrating for the staff."

The development team included a physical therapist, two physicians, a physician assistant, two nurses, a licensed professional counselor and two educational material design experts. "It certainly does emphasize an interprofessional approach," Corcoran said. "As I saw palliative care interest start to increase at George Washington, I also saw interprofessional [interest] increase at George Washington as well. ... The benefit resonates across both of those areas."

The GEPaC framework consists of disease management, pain and symptom management, communicating goals of care, supportive and compassionate care, and knowledgeable and skilled practitioners in geriatric care and gerontology.

Person-centered care

The development team took its cue partly from the Patient-Centered Outcomes Research Institute (pcori.org), which was established by the Affordable Care Act of 2010. "This is starting to get some momentum at a different level. GEPaC is the type of thing that’s very consistent with PCORI," Corcoran said.

This is a paradigm shift toward putting older adults in charge of managing their own disease processes, Cocoran said. "You become partners with them in terms of symptom management. We help them get involved in the goals of care, put them in charge of the goals of care, and make sure that we’re addressing all kinds of other types care needs and we have [assembled] knowledgeable and skilled care professionals who are able to deliver that paradigm of care," she said.

One place this especially comes into play is during a transition, such as when a patient receives bad news about his or her condition, or that the plan of care is changing, Corcoran said. "Anticipatory guidance is a very nice concept in that we begin to look at the types of things the person could anticipate could be happening to them," she said. "What you want to do is provide people with some guidance about what might be next. ... This is what you might experience. These are the types of things you should think about."

Other transitions might include change in cognition, caregivers or financial situation. "One of the biggest transition points is change of residence, change of setting," Corcoran said.

Barriers to person-centered care include: the patient’s own judgment, the culture of a facility, a history of the physician being viewed as "the boss," the change from a cure focus to palliative focus, reimbursement issues, and family and societal barriers, according to OTs in the audience at the presentation.

"This seamless transition is not because we’re improving the way people are talking to each other around the person — we’re really putting them at the center of care," Corcoran said. "And it really allows us to direct our attention to improving quality of life."

Building GEPaC

"We started with the literature. We started with a very qualitative approach to the evidence," Corcoran said of the preliminary work done on GEPaC. The team drew out some themes, such as dealing with family conflict, and built modules around that evidence, she said. "Some of these themes you really have to keep coming back to. These modules can be standalone, but for the most part what we really want to do is make sure we have some messages that are powerful enough that we can draw them through all the modules," she said.

The Quality of Life module "will be the grand finale where we come back and revisit about all these themes and talk about quality of life," Corcoran said.

As far as turf issues, each discipline is a "brick in the wall" and where they overlap is where they are strongest, one member said. For example, a client will hear about energy conservation from a number of different professionals from a number of different perspectives. "Then it becomes a much stronger lesson," Corcoran said.

OT needs of dying patients

Terminal patients have a variety of occupational therapy needs, including maintenance of quality of life through participation in meaningful occupations, staying connected in important relationships, maintaining control in decision-making and support for spirituality, Corcoran said.

"Occupational engagement can facilitate feelings of actually living," she said. "It doesn’t matter if it’s six months, or a week, or a day before they actually die." •

Natasha Emmons is the editor of Today in OT.