Dr. Christopher Comfort, chief operating officer for Calvary Hospital in New York City, oversees the organization’s operating budget as well as all patient care. He is also an ambassador for the hospital’s CalvaryCare program, designed to educate the health care community and the public about palliative care and hospice.
Calvary is the only acute care hospital in the United States that is focused almost exclusively on hospice and palliative care. The institution has been in operation for more than 100 years, inspired by a group of women in Europe who brought patients into their homes to receive care. Many of these patients had been rejected by hospitals due to lack of funds or complex care needs.
Hospice News sat down with Comfort to talk about Calvary’s hospice and palliative care model, its work to educate clinicians on the nature of those services and how to provide them, as well as the organization’s partnership with other local resources.
Calvary is described as the only acute-care hospital that’s dedicated to hospice and palliative care. Those services are often grouped into what’s called the post-acute space. How would you characterize this in an acute care setting?
In terms of its interest in end-of-life, hospice and palliative care, Calvary is an institution that did those organized medical activities before anybody even thought up the term “palliative care.” That conversion created a revenue stream for the hospital, where before it was entirely dependent upon donations.
Major institutions in New York, including some of the finest cancer hospitals in the United States, send patients to Calvary. Those institutions weren’t in the position of having to develop end-of-life programs of their own because they had such an expert program to whom they could refer their patients. We’ve cared for about between 15% and 20% of the cancer deaths in New York City and surrounding areas.
We’re the only hospital that CMS is defined with a title of an extended neoplastic disease hospital.
Can you give me a sense of the scale of your home-based care services versus other inpatient and outpatient care? Are you able to say what proportion occurs in the home?
The program began as an inpatient program and developed throughout the 70s, 80s and 90s. In the late 1990s, we began a hospice and home care program with the primary interest being hospice. Most of the home care services these days would be called palliative home care.
Those are patients with chronic and deteriorating diseases that are in the late stages of their illness, and they are provided with home care services related to those diagnoses distinctly different from the typical home care service.
We have probably about a 30% to 40% cancer diagnosis population in the home care program. Hospice has grown steadily. It is sitting in 11 either counties or boroughs around and in New York City. So it has a very, very large geographic area that has grown over the years.
Now it’s about 50/50 in terms of services offered on the inpatient side and services offered for hospice. We currently are sitting at an daily inpatient census of about 400 patients a day with vast majority of those patients receiving care in the home. We do have a number of institutions that we do gap services in and are currently providing all the general inpatient level of [hospice] care for the Presbyterian health system, including Columbia, Cornell, and the affiliated hospitals.
Throughout the pandemic, a lot more care has moved into the home setting. In your experience at Calvary, have you seen more demand on the home-based care side than on the inpatient level in the past couple of years?
I would say over the last probably five to seven years, there’s been exponential growth of care in the home setting. Most of that has been facilitated by some sophistication of the hospice providers in the New York area.
Over the last two years COVID was a bit of a unique situation — in that it certainly increased the available clientele appropriate for hospice dramatically — but it did it in a kind of an unusual way.
It took relatively well people and then took them to very late-stage acute disease with patients that were going to expire of their disease and move them into the home setting very, very quickly. The demand for hospital beds and the lack of availability of nursing home beds for that population put a profound stress on hospice services.
Throughout the city, it was interesting to see most of those discharges coming out of the hospital not referred to home care, and your typical home care services. This was such a desperately ill population. These were patients that were moved specifically to the home setting because they were actively dying and needed the support services of hospice. Hospices with a more comprehensive program were the best place to place those patients.
In addition, we found over the two-year period of time of COVID that the need for referral out of the hospital to a setting such as our inpatient setting was necessary just in terms of patient volume and patient demand. New York City to its credit, very specifically planned for post-discharge care of patients who were really severely ill, typically with respiratory conditions that prevented transfer to the home setting. We really became the referral center for post-COVID discharges.
One thing that really struck me was your nurse residency program. Could you talk a little bit about how and why this program came to be?
This program came out of pure staffing needs. In the home setting in particular, hospice nurses do yeoman’s work. They not only do yeoman’s work in terms of the personal association and the services that they offer, but they are a brand of nurse that works highly independently and cooperatively with a physician staff associated with hospice.
Hospice nurses are often our front line who go out and have to make tough care decisions in the home setting in consultations with physicians. That has typically required nurses with years of experience doing their work, whether that’s acute care, nursing or community-based nursing, and those nurses are becoming harder and harder to find.
It’s highly competitive for attracting those nurses to work in different hospice organizations. So our idea was to begin the process that would allow us to hire nurses that may have been involved in the field for a long period of time, but also allowed us to attract nurses who were new graduates and those who had worked in different areas that were now interested in hospice and palliative care.
It requires dedication and maturity to go into that field for nurses, and we wanted the opportunity to attract those two specific groups of nurses and provide them with a training experience for their first year that would allow for some sophistication beyond what a typical first-year nurse or a nurse moving into the field would have. Then we provide them with a reason for maintaining themselves in that position for long periods of time.
The program involves a very specific didactic section, including certification in palliative care and hospice for nurses, allows for a very particular preceptorship program that walks them through experience with end of life in the inpatient setting, but also provides them with specific experience in the home setting.
We’ve also set up a process of observation of those nurses that are in the home setting, virtually. This allows us to observe several of those nurses virtually and provide input and feedback to those nurses on a real time basis through this communication platform.
What do you think is necessary on a national level to address the lack of professional education in the field?
These kinds of models are reproducible on a national level. There has been interest in the social work community for certifications in palliative care. We worked with the social work schools at Columbia University, New York University, and most recently, Fordham University, as they have developed programs in what they call palliative social work.
One of the difficulties in educational programs like that is it’s hard to have a coordinated site where an individual can get an extensive amount of experience working with patients and their families.
When you think of the acute-care settings, the stays of these patients and families are quite short. It’s hard to develop a training program in the acute care setting that addresses the needs of these patients.
Concentrating on the very unique needs that patients and families have at the end of life, most nursing schools have developed fairly sensitive programs in training for nurse practitioners for palliative care, but have not been able to develop the resources for provision of these services.
One of the major reasons for that is again, a problem of access to an appropriate patient base. I mean, we have the benefit of having 225 patients on an inpatient side and 400 patients on a home-setting side. So we are able to take a large number of nurses who will train in this kind of a situation and have an adequate patient and family base to give them the experience of what they need.
Nationally, the resources for this are available, but the development of the true associations between nursing schools and nursing education programs, and institutions and community resources to make that happen is really what has to occur.
Calvary has been working with some emergency medical services (EMS) agencies to provide additional support to some of its patients. Can you tell me how those partnerships work? What do the EMTs offer and under what circumstances would they become involved?
We have done a training program for the fire department in New York, where it’s been years since New York City consolidated EMS services under the control of the fire department. We had the physician Director of Emergency Services come to us, and we had a talk about what an EMS provider needs to know about end-of-life care and palliative services.
To facilitate the work that we did, we designed a curriculum for them. They began to send EMS workers to us, to the point now where all EMS in New York City rotates through here in an educational program, and all supervisors of EMS spend time with us on a consistent basis.
It allows them to be exposed on a consistent basis to both inpatient and home settings of patients who are dying. But it also allows EMS workers to reflect upon some of the issues they go through related to care of patients.
In the first section that we went through with senior EMS staff, we talked about the types of patients that they cared for their typical pickups and realized that 80% of the runs that EMS patients go out on are to pick up patients who have a prognosis of six months or less.
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