Hospice + Palliative Medicine Fellowship - Clinical Opportunities

The Tufts Medical Center palliative care service receives approximately 60 new consults monthly and carries a daily census of approximately 20 active patients. Consults come from various sources, including the advanced heart failure team, the medical, surgical, and subspecialty ICUs, oncology, infectious disease, renal, and general medical services. While in the inpatient service, the HPM fellow will join a team that includes physicians, a nurse practitioner, a nurse navigator, and a social worker. The fellow will meet with the supervising physician, nurse, and social worker each morning to assign new consults, review cases and plan family meetings. Fellows will see patients daily, communicate with the referring team, complete appropriate documentation, and precept each patient with a staff member. Fellows will join the team at weekly inter-disciplinary team meetings, attend clinical and educational conferences, participate in the education of rotating learners and alternate with other team members in leading weekly didactics.

At VA Hospital in West Roxbury, the palliative care service sees 40 new patients per month and is staffed by a physician, NP, SW, and RN team. Similar to the Tufts MC inpatient service, fellows will see patients daily, precept with their supervising physician, communicate with the referring team, and involve other members of the palliative care team (e.g., social worker) when needed and appropriate. Fellows will participate fully in clinical and educational conferences and interact with other learners rotating on the service.

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The strongest evidence for the impact of palliative care is for the integration of palliative care earlier in the disease course and in the outpatient setting. Thus, Tufts Medical Center is committed to providing fellows with a robust outpatient educational experience that prepares them to deliver palliative care in the ambulatory setting. The outpatient palliative care practice is growing, with over 1,000 encounters in 2022.  Palliative care providers see patients in clinics embedded in oncology, nephrology, and pulmonary. Patients are referred for pain, non-pain symptom management, psychosocial support and advance care planning.

Fellows will be assigned a half-day clinic session each week. The fellow is expected to prepare for these visits in advance. All patients will be precepted by an attending physician. The fellow is expected to communicate recommendations to the referring provider, prescribe medications, do phone call follow-up when necessary and complete documentation promptly. Patients will be booked with the fellow whenever possible to ensure longitudinal care. If patients from their clinic are hospitalized or referred to hospice, fellows will be encouraged to see them in these settings.

In addition to the longitudinal clinic, fellows will have multiple weeklong outpatient immersion experiences throughout the year. During these weeks, the fellow will see patients in the clinic for several half-day sessions. This will allow them to see patients outside their longitudinal clinic and ensure diversity of diagnoses and experience in the ambulatory setting. They can visit longitudinal clinic patients in another setting (home, long-term care, hospital). During these weeks, didactics will focus on ambulatory topics, such as opioid stewardship, practical aspects of prescribing (e.g., costs, prior authorization), prominent outpatient symptom management (e.g., fatigue, anorexia, sleep disorder), the assessment and facilitation of adaptive coping, and logistics of telemedicine. Fellows will be asked to present.

Tufts Medicine Care at Home serves as the site for the home hospice rotation. Deeply committed to providing emotional and physical support, the clinical team includes the Hospice Medical Director (HMD) and Associate Medical Directors, Nurse Practitioners, nurses, social workers, home health aides, bereavement counselors, a volunteer coordinator, spiritual care counselors, volunteers, and other therapists, including music therapy, as needed. The Hospice Medical Director and Associate Medical Directors have all served in academic appointments and worked for at least fifteen years in hospice and palliative care clinical practice.

We are proud to participate as a level 3-member in the We Honor Veterans program, a National Hospice and Palliative Care Organization program, in collaboration with the Department of Veterans Affairs. During their rotation, fellows will make home visits primarily in conjunction with one of the hospice nurses and/or the Hospice Medical Director or Associate Medical Director and less frequently with another team member. Occasionally, fellows will visit patient homes independently toward the end of the rotation. Fellows will participate in weekly IDT meetings, presenting patients they have seen. The didactic curriculum will include lectures on the imminently dying syndrome and non-oral medication administration routes. The hospice medical director will meet with each fellow to review key components of hospice administration, including regulatory, administrative, legal, and ethical competencies, cost-effective policies and clinical skills appropriate for hospice patients.

High Pointe House has 21 private suites for patients and spacious common areas, including a kitchen, play area, library, and garden, to support the needs of families. High Pointe provides a general inpatient (GIP) level of care and routine hospice care for patients unable to receive such care at home. Patients on GIP have intense medical and/or nursing needs, such as the management of pain or other acute symptoms requiring IV medications. The site has 24/7 coverage to address these complex symptoms. Fellows will round on GIP patients with the supervising physician and spend time with various team members, including the on-site bereavement and spiritual counselors. The experience will educate them on addressing all aspects – physical, spiritual, psychological and existential – of suffering in patients at the end of life.

The palliative care team for the hospice and palliative care unit consists of a physician, nurse practitioner, social worker, nurse manager, chaplain, speech pathologist, pharmacist, nutritionist, recreational therapist, and kinesiotherapist. The hospice and palliative care unit cares for 15 veterans and accepts patients for both end-of-life care and ongoing symptom management and support during palliative chemotherapy or other supportive care.

During this rotation, the fellow will round daily with the care team, including the physician, nurse practitioner, and charge nurse. The fellow will initially manage patients, accept admissions with close supervision from the attending physician, and move to a more independent model as the year progresses. The fellow will learn how to triage admission requests, coordinate family meetings, run an IDT meeting, develop a care plan, and discharge patients from hospice. The team meets for IDT and care plans weekly, and the fellows will have the opportunity to run this meeting toward the end of the rotation.  The fellow will be expected to complete admission notes and daily progress notes.

The fellow will have the opportunity to work with other learners, including psychiatry interns, physician assistant interns, psychology interns, and pharmacy interns. The fellow will also have the opportunity to educate the team and will be expected to educate on one topic of interest during the rotation.

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HPM fellows will gain exposure and expertise with pediatric patients from a variety of sources. They will see inpatient consults from the neonatal intensive care unit (NICU), precepted by Dr. Tamara Vesel a pediatric palliative care physician and the Division Chief. They will also rotate at the New England Pediatric Care nursing home, an 80-bed facility designed for children who are medically complex and have severe cognitive and neurological impairments. During this experience, they will be supervised by Dr. Harry Webster, a pediatric physiatrist and Medical Director of New England Pediatric Care. They will see patients with Dr. Webster in the clinic and round with other interdisciplinary team members (e.g., physical therapists, occupational therapists, social workers, speech-language pathologists, and nurses) to learn their role in caring for their seriously ill children. Finally, fellows will see children and young adults when referred for hospice care with Tufts Medicine Care at Home or High Pointe House inpatient hospice. Patients from NEPC referred to hospice are commonly seen by Tufts Medicine Care at Home, which would allow fellows to see patients at two different locations and stages in their illness trajectory.

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Each fellow has the opportunity to spend at least four weeks in a focused experience. For fellows interested in an academic career, this is a chance to advance a scholarly project, which can be an educational endeavor, a quality improvement project, a clinical innovation, or other scholarly work. The fellowship will provide guidance and mentoring and help craft time to maximize productivity.

Fellows can also use this time to gain additional clinical exposure. The program director can help arrange rotations with allied fields, such as interventional pain, radiation oncology, physical medicine and rehabilitation, spiritual care or social work.