Traveling palliative care team serves Northern Hills patients

Traveling palliative care team serves Northern Hills patients

Phoebe Breed, DNP, considers it an honor to work with geriatric patients receiving palliative care. “These patients are often vulnerable due to their frailty, social situations and sometimes cognitive decline, and they need someone to listen to them, understand what is important to them and advocate for them,” she said. “I am honored when I get to be that person.”

Phoebe is a part of a team of Monument Health providers and caregivers called the Geriatric Palliative Care Team of the Northern Hills. The group is based out of the Medical Clinic on North 10^th St. in Spearfish, and their model not only expands access to palliative care in a rural area but has improved patient outcomes. Rather than having patients travel to the clinic, the team travels to long term-care and rehabilitation facilities, assisted living facilities, a hospice center and to individual homes. “Our homebound and assisted living elders are often unable to present to the clinic for timely interventions, so it’s imperative that we go to them,” Phoebe said.

Deborah Kullerd, M.D., CM.D., had the initial vision to transform the clinic practice to a traveling care team when she realized it was becoming increasingly difficult for physicians to devote the necessary time to these patients. She saw an opportunity to design a care model that not only made it easier for patients to receive care but to ensure treatments were aligned with their personal preferences and goals.

Over 10 years, Dr. Kullerd built a team that now includes two physicians, two nurse practitioners, two registered nurses and a clinical assistant. The group has decreased rehospitalization rates, decreased antipsychotic utilization rates and increased the ability to provide timely, accessible care that identifies and respects patient values and goals. They currently serve roughly 360 patients.

All team members are competent in discussing goals of care and advance care planning, and this is one of the most important parts of the job, according to Phoebe. “It’s important to find the right time to bring the family together to have those conversations. That’s a major goal of our team. Especially with patients who have conditions such as dementia, the sooner you can have those conversations, the better.”

The team’s success, according to Phoebe, has a lot to do with their constant communication and familiarity with patient situations at all locations. They take time as a group to discuss complex cases as well as changes occurring at the facilities they visit. “That team time is pivotal to our success and is truly the cornerstone of how we operate,” she said.

Last week, Phoebe represented the team at the Center to Advance Palliative Care National Seminar in Atlanta. “I hope others who are working to provide patient-centered geriatric and palliative care in a location like the Northern Hills can be inspired that a model like this is working well for us and hopefully use that information to build their program and serve more elders.”

In above photo – The Geriatric Palliative Care Team of the Northern Hills (left to right): Alyssa English, CA, Kari Griffin, RN, Patricia Fogarty, M.D., Deborah Kullerd, M.D., Jenni Karp, CNP, Phoebe Breed, DNP and Shelley Sedivy, RN.