Taking Healthcare by Storm: Industry Insights with Miranda Broyles

In this captivating episode of Taking Healthcare by Storm, delve into the world of expert insights as Quality Insights Medical Director Dr. Jean Storm engages in a thought-provoking and informative discussion with Miranda Broyles, APRN, FNP-BC, ACHPN, Director of Palliative Care Services at HospiceCare.

If you have any topics or guests you'd like to see on future episodes, reach out to us on our website. 

This material was prepared by Quality Insights, a Quality Innovation Network-Quality Improvement Organization under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. Publication number 12SOW-QI-GEN-041924-GK

Transcript

Welcome to Taking Healthcare by Storm, Industry Insights, the podcast that delves into the captivating intersection of innovation, science, compassion, and care.
 
 In each episode, Quality Insights Medical Director, Dr.
 
 Jean Storm, will have the privilege of engaging with leading experts across diverse fields including dieticians, pharmacists, and brave patients navigating their own healthcare journeys.
 
 Our mission is to bring you the best healthcare insights, drawing from the expertise of professionals across West Virginia, Pennsylvania, and the nation.
 
 Subscribe now, and together, we can take healthcare by storm.
 
 Hello.
 
 Welcome back everyone to Taking Healthcare by Storm.
 
 I am Dr.
 
 Jean Storm, Medical Director at Quality Insights.
 
 Today, I am pleased to bring you a guest to provide some elucidation into palliative care services, which is something that maybe you have heard of, but maybe you kind of link it to hospice care services.
 
 So today, we're going to be talking about the importance of palliative care, and I am pleased to welcome Miranda Broyles, who is Director of Palliative Care Services of HospiceCare West Virginia.
 
 Miranda, welcome to the show.
 
 Thank you.
 
 Thanks so much for having me.
 
 Yeah, we are so pleased to have you.
 
 So let's just jump right in.
 
 Can you tell us about your current position?
 
 I am currently the Director of Outpatient Palliative Care Services, which is a part of HospiceCare.
 
 I am also a Hospice and Palliative Care Certified Family Nurse Practitioner.
 
 So daily, for my most daily things that I do, I oversee the daily functionality of our Outpatient Palliative Care Program that covers seven counties in West Virginia for home visits.
 
 That also includes assisted living facilities in those seven counties.
 
 And we also do inpatient consultations for two hospitals in West Virginia.
 
 I'm also a field nurse practitioner, so I'll see patients out in the field with the rest of my staff.
 
 I'll see patients in the hospital.
 
 And then I'm the Treasurer for the West Virginia National Ethics Committee, and I sit on the Test Development Committee for the HP&A.
 
 So, not a lot of spare time.
 
 No, I was going to say, you wear a lot of hats.
 
 Is there anything else anyone needs me to do?
 
 So, how did you come to do what you do now?
 
 A little bit by default, but very, very glad I did.
 
 So, I've been a nurse for almost 20 years.
 
 I started my career at one of our local hospitals in cardiac surgery.
 
 Thought that's where I would be my whole career.
 
 I spent many years in the cardiac world, and my position before this one was lead nurse practitioner for cardiothoracic surgery.
 
 So, I came into this position during a time when our local hospital was making some major cuts, and some of the nurse practitioners, including myself, were part of those cuts.
 
 So, I challenged myself on an open position I was completely not knowledgeable about, but after taking the position, I knew it was where I was meant to be.
 
 So, over the past five years in this position, I've seen myself grow professionally and personally by being a part of palliative care and hospice, and I can't imagine doing anything different now in my career.
 
 Oh, that's so wonderful when you're in a position where you make a difference and you're really getting some life satisfaction.
 
 Yes, right where your heart is, and that's where I am.
 
 Yes.
 
 So, have you always lived in West Virginia?
 
 I have.
 
 I'm a West Virginia girl through and through.
 
 I was raised in the small town of Big Chimney, West Virginia, only really the river people probably know where Big Chimney is.
 
 It's right outside of Elkview, West Virginia.
 
 I now live in Charleston with my husband and two children.
 
 I am a devout Mountaineer fan, so in my spare time when I'm not at work, you'll find me on the sidelines of some West Virginia soccer game, baseball game, basketball game, cheering on the Mountaineers with my kids.
 
 I love to travel with my friends and family and explore new places, but I always find myself back home, which is always here in West Virginia.
 
 Yeah, it is a fascinating place.
 
 I'll tell you, I practiced there for a while and I traveled back there quite often, and every time I cross over back into West Virginia, I have to play the song.
 
 And I'm always amazed at sports events when they play country roads.
 
 Everyone sings.
 
 Everyone sings.
 
 Yes, even kids who play sports here in West Virginia at the college level who aren't from West Virginia.
 
 So they've come in as transfers and you still see them singing country roads.
 
 I'm like, is this part of their initiation for these college careers that they have to learn this song?
 
 But it's great.
 
 It's wonderful.
 
 I love the tradition.
 
 So can you tell us the difference between hospice and palliative care?
 
 Sure, I'd love to.
 
 I'll start with palliative care because that's mostly what I do as palliative medicine.
 
 I do help on the hospice side.
 
 And as I'll talk, you'll hear palliative and hospice have a lot to do with one another.
 
 We do work hand in hand.
 
 I call them our sister because a lot of our patients end up on the hospice service.
 
 So as a palliative provider, you have to know hospice to know palliative.
 
 So palliative medicine is specifically designed for people who are suffering with a chronic illness.
 
 For example, CHF, COPD, dementia, cancer, just to name a few.
 
 These patients seek palliative care while they're still undergoing treatment.
 
 So they're very much in a curative phase of their chronic illness.
 
 They may be undergoing chemotherapy or dialysis.
 
 They're still going to their specialist appointments.
 
 So the palliative care works hand in hand with their primary care physicians and their specialists to decrease symptom burden related to these chronic illnesses.
 
 Their palliative care is paid for through their primary insurance, and they remain under the care of their primary care physician or their specialist, and their insurance continues to pay for this treatment and these treatment options, these curative treatment options, these aggressive treatment options in conjunction with palliative care.
 
 So patients receive similar services to hospice, such as like the symptom management part, counseling services, goal clarification.
 
 And in many instances, palliative care is like a pre-hospice program.
 
 About 60% of our patient population will eventually choose hospice.
 
 Most patients on palliative care service have a life expectancy of about a year or less, but that's not a requirement for palliative care.
 
 We've had patients on service for quite longer.
 
 I have a patient with a very slow progressive neurological disorder, and I've had him for six years helping palliate those symptoms.
 
 So there isn't like a life expectancy kind of cut off with palliative care like there is with hospice.
 
 Palliative care can be provided in a home setting.
 
 We do see patients in assisted livings.
 
 We see patients in the hospital for palliative goal clarification conversations.
 
 And even in some instances with some palliative care programs, and Dr.
 
 Storm and I need to collaborate with this in skilled nursing facilities.
 
 So we did do skilled nursing facilities before.
 
 It's something we're looking at getting back into.
 
 So there's quite a good amount of places palliative care can be provided.
 
 Now the medications on palliative care are still prescribed by a family doctor.
 
 The palliative care provider just helps with med reconciliation, de-prescribing, making recommendations for medication changes if those meds are ineffective.
 
 But palliative care providers do treat acutely.
 
 So if we go in and we see a patient may have an acute urinary tract infection, an acute pneumonia, we're going to treat those acutely and let their primary care physician know we treated those.
 
 We can obtain x-rays in the home when we feel like there may be a small fracture or there may be pneumonia.
 
 We can also get labs.
 
 But the primary care physician and the specialist remain the key train conductors here.
 
 So they're always driving the care for the patients, and we are part of that train.
 
 So a little bit that I skipped about who we are and who provides care.
 
 We have a team of nurse practitioners.
 
 I have seven wonderful nurse practitioners.
 
 We have a medical director that helps with the care of our patients and helps us with insight.
 
 We have two nurses, and we have a social worker and lots and lots of community resources for palliative care.
 
 So that was a mouthful about palliative care.
 
 So on the flip side is hospice.
 
 So hospice and palliative care get clumped together a lot, but we are different in a lot of ways.
 
 So hospice is a program designed for patients with a life expectancy of six months or less to live.
 
 It involves end of life care for patients who are diagnosed with a terminal illness.
 
 So hospice services are more centered around quality of life and symptom management for end of life versus palliative care where patients are still in the curative aggressive stage.
 
 While on hospice, again, patients are no longer seeking that curative aggressive treatment, but they've chosen the path of comfort.
 
 Now in saying that, some forms of treatment patients can still receive while receiving hospice, such as blood transfusions or lung or liver drainage like thoracentesis or paracentesis.
 
 Those are still done for symptom management and comfort for patients on hospice.
 
 But primarily patients seeking hospice are seeking comfort in the end of life.
 
 Hospice is similar to palliative in their settings.
 
 So hospice can be provided in the home setting, assisted living, skilled nursing facilities.
 
 The difference is that hospice has not all hospices, but our hospice particularly has hospice houses where care can be provided in the end of life.
 
 Those hospice houses serve also as a place for respite.
 
 So that's for caregiver support.
 
 So every five days, every 30 days, a patient can receive respite care at our hospice house, 24-hour care, and then return back home for hospice.
 
 And patients can also go to these hospice houses for uncontrolled symptoms.
 
 So say, for example, a patient's having uncontrolled pain at home, we can bring them to the inpatient unit.
 
 They can be monitored 24 hours a day for however many days to get their symptoms under control with an in-house doctor, and then they can return home with hospice services.
 
 Similar care team, they have a medical director, they have nurse practitioners, nurses.
 
 One of the big differences in the supportive care for patients is they have a certified nursing assistant.
 
 So they're getting bathing assistance about three times a week, and they have a very robust bereavement and spiritual program on the hospice side, versus palliative care where we usually outsource our spiritual care to the community or we use our social worker.
 
 So very much a mouthful, but I hope that helps to explain the difference in how our palliative and hospice programs work.
 
 That was very comprehensive, a great description of the difference in the two services, and I just want to highlight, and I think that people maybe don't understand that with palliative services, you don't need to, there's no life expectancy, so you can remain on palliative care services, like there's no limit, number one.
 
 And number two, I just want to highlight the wonderful aspect that patients can receive testing, lab tests in their home, so they don't end up in the emergency room.
 
 We all know the state of the emergency rooms nowadays, but to have those services available in the home is just, I think it's just fantastic, really relieves a burden, I think, for people with chronic disease.
 
 It does.
 
 And a big thing we do, too, I didn't mention, is goal clarification.
 
 So sometimes we're the first person to see them in their home after they've been diagnosed with a stage four cancer.
 
 And so they've been given all this information in the hospital.
 
 They've, you know, if you come in and someone says the word cancer to you, that's probably the last thing that you hear.
 
 So all the things that they talk about afterwards, treatment options, how are you going to get rods, you know, what is the cost, what kind of follow up do you need?
 
 They don't hear it.
 
 Might be on a piece of paper they brought home.
 
 So we are the next person that comes in as palliative care to help with that goal clarification.
 
 Tell us what you heard.
 
 Tell us what you understand.
 
 Let us help you understand this illness and this diagnosis.
 
 And let us help you with choices.
 
 Let us help you decide exactly what you want for your care.
 
 Because maybe this isn't the right path for you.
 
 So that's a big piece of what we do as well.
 
 Oh, so important.
 
 So do you feel that there's a particular need for palliative care services in West Virginia?
 
 I don't just say that from my heart because palliative care is my joy and my passion.
 
 I say it because I truly see the need in West Virginia.
 
 Now more than ever with our aging population, a lot of our young population are moving out of state.
 
 So West Virginia is truly one of the oldest states in West Virginia when it comes to the age, actual age of our population.
 
 So of course with age comes chronic comorbidities.
 
 I see it so often.
 
 80-year-olds taking care of 80-year-olds.
 
 So the need for palliative care in our state is imperative.
 
 We're also a state that lacks aging and chronic care support.
 
 While we have run across so many wonderful agencies in our state that help the aging population, it still isn't enough.
 
 So I feel like having a palliative care provider, having robust palliative care programs across the state is even more important in a state where there aren't enough resources.
 
 And I also feel like having a palliative care program for West Virginia residents helps give them a voice, like I was just talking about.
 
 It helps them understand their health care.
 
 It helps with health care literacy across the state.
 
 It helps patients and families understand exactly what is expected, exactly what is to come with a chronic illness, and it helps give them choices in their health care.
 
 I really love that term, chronic care support.
 
 I mean, I think we should be using that much more, you know, with the high incidence of chronic disease in our population.
 
 Absolutely.
 
 So what regions does HospiceCare West Virginia cover in the state?
 
 Sure.
 
 HospiceCare covers, our hospice program covers 16 counties in West Virginia.
 
 So I don't have those memorized, but you can find those counties on our website, which is hospicecarewv.org, which will tell you the 16 counties that we cover.
 
 Our palliative care program covers seven of those 16 counties, which is Kanawha County, Putnam County, Greenbrier, Clay, Fayette, Nicholas and Jackson.
 
 There are also other great hospice programs across the state that cover many of those other counties that offset those 16 counties or seven counties that we don't cover.
 
 Most of these hospices also include a palliative care program that we work hand in hand with.
 
 So I'm part of the West Virginia Hospice and Palliative Care Network, which is a group of partnered hospice and palliative care programs in West Virginia who work together to improve access to hospice and palliative care services in our state.
 
 So essentially, we try to come together to make sure that our representation of services offered is cohesive.
 
 So I just want to touch a little bit on the pandemic, and I know we all kind of want to move beyond the COVID pandemic, but I really feel like it impacted health care tremendously.
 
 So how did the pandemic affect palliative care services in West Virginia?
 
 It was hard for us.
 
 We really had to put our thinking caps on on providing care and how we would reach our patients, how we would calm their fears and ease their fears.
 
 We were scared, our patients were scared.
 
 There are a lot of unknowns out there, but I feel like as a group, as palliative care providers, we handled the pandemic as brave health care providers would.
 
 I'll say it anywhere and I say it anytime I can that I have the most phenomenal group of providers.
 
 And they all stepped up to the calling during the COVID pandemic and provided care for our patients.
 
 You know, we are primarily a home-based program, which essentially means a face-to-face program.
 
 So we are seeing patients face-to-face in their home.
 
 This isn't a program where you can avoid patient contact.
 
 So this did require us to get our N95 masks out and our PPE out and go into patients' homes and answer our call to be health care providers.
 
 And one thing that did change in our program is how we delivered care.
 
 So during the time of the pandemic, telehealth was also coming around.
 
 It had just started to become popular.
 
 So we worked very diligently to build a robust telehealth program so that we could reach our patients who might be fearful of a face-to-face contact with us or their health care provider.
 
 So this allowed us to still provide symptom management.
 
 It allowed us to see maybe new wounds that needed a home health referral.
 
 And it also allowed us to report back to the physicians and specialists how their patients were doing because they weren't going out to their visits to their PCPs.
 
 So it allowed us to be able to help the family physicians as well by using this telehealth platform.
 
 We also built a very prominent mental health program.
 
 Mental health was huge during the COVID pandemic.
 
 It's still big.
 
 There are still ramifications of mental health from COVID.
 
 So we built it not only for our patients, but for our employees.
 
 We prayed together.
 
 We came together often on FaceTime or Teams to talk about our fears, to support each other.
 
 You know, in the midst of COVID, when one of us actually contracted COVID, we were a supportive voice.
 
 And we also did the same for our patients.
 
 They were scared.
 
 You know, they're hearing on the news that patients with chronic illnesses were at even higher risk for death from COVID.
 
 So they leaned very heavily on palliative care counseling and were searching for a support system to help them get through their fears.
 
 And I'm proud to say we were that resource.
 
 It's really wonderful to hear some good things that came out of the pandemic.
 
 I appreciate that.
 
 So do you feel that the population of West Virginia in general understands the purpose of palliative care services?
 
 I wish I could say yes.
 
 I'll have to say no, but I think we're getting there.
 
 I feel hospice and palliative care are still very much clumped together, not only by the general population of West Virginia, but by health care providers, hospitals, clinics.
 
 So we work very diligently to provide education across our state on the difference between hospice and palliative care and exactly what palliative care can do for patients, but there are still a lot of misconceptions.
 
 I'm super proud of how far we've come, but there's still a lot of work to do.
 
 When I first started with palliative care, we had around 120 patients.
 
 Since then, we've seen our census grow to over 450 patients in five years.
 
 So huge leaps and bounds for the referral process and for patients understanding who we are and what we can do, as well as the providers understanding how we can help their patients and how we can collaborate with them.
 
 I still think we have a ways to go, but we'll still continue to fight that good fight of education and helping West Virginia understand palliative care.
 
 Yeah.
 
 So how would a patient come under the services of palliative care?
 
 Sure.
 
 Palliative care referrals can come from pretty much anywhere.
 
 So it can come from...
 
 We get a lot of patients from a hospital stay.
 
 So the hospital case managers will recognize the need for palliative care at home.
 
 A patient can request palliative care services for themselves.
 
 It can be a family, a physician, a specialist.
 
 Once we get that referral, though, we do work hand in hand with a family physician.
 
 So the patient does have to have a family physician or a specialist that is in agreement and involved with the palliative care referral.
 
 So if we receive it from an outside source, we will let them know and we will get their agreement for collaboration.
 
 So once that gets started, then we contact the patient, let them know that everything is a go, that everyone's in agreement for palliative care services, and then we get someone out to the home to introduce our services and talk about palliative care.
 
 It's like a seamless process.
 
 It seems like it, right?
 
 We used to do an order, so we used to do a system where we would get the referral and then we would send a paper for a signature, but it's not necessarily something that is required.
 
 We were kind of mimicking the hospice process, and then we stopped and said, why?
 
 We don't necessarily have to have this signature.
 
 We do have to have the collaboration, so let's send a letter letting them know that we've received this referral.
 
 I don't know if they have any questions to call us, but hey, let's collaborate, and that has worked wonderful for us.
 
 Yeah, that's great.
 
 So one last question.
 
 Can you share with us any patient success stories in palliative care?
 
 Sure.
 
 We love our success stories, but I think that the most important part of sharing success about palliative care is really sharing about quality of life.
 
 That's what we do, and so we love to see the joys and the quality of life that patients get from palliative care.
 
 So every patient who is able to go to their child or grandchild's graduation because we helped their chronic disease symptoms get under control so they could make it to a graduation or a wedding is a success story for us and for them.
 
 Or even smaller milestones like a patient walking to the bathroom without shortness of breath or seeing a patient gain a few pounds after they've had extreme nausea and vomiting with chemotherapy.
 
 So these are the joys and the journeys that we walk with the patients and the victories that we love to see with them.
 
 So we celebrate these victories and walk these journeys with them.
 
 We love to see improvements, but more importantly, we love to see them living and loving life despite their chronic illness burden because that's what palliative care is all about.
 
 Absolutely.
 
 Well, thank you so much.
 
 Can you tell us how people can get in touch with you?
 
 I know you mentioned the website.
 
 Can you just mention it one more time?
 
 Our website, which covers all of our services, is hospicecarewv.org.
 
 And on that website, you're going to be able to click all of our different services.
 
 So you'll be able to check a place where you can go in and learn all about hospice.
 
 There's also a separate place for palliative care.
 
 There is a separate place for bereavement as well.
 
 And then there's a separate place, too, for our newest addition, which is our Home Health Services.
 
 So it's a pretty easily navigated website.
 
 Palliative care specifically, if you call 304-941-1951, that will get you directly to our palliative care intake coordinator.
 
 Even if you have generalized questions about what we can offer that maybe I didn't answer today, questions about your family member, questions about resources, we can make sure to get you to the right person.
 
 Excellent.
 
 Miranda, thank you so much for joining us with this informative and inspiring conversation.
 
 Absolutely.
 
 I'm honored that you had me today.
 
 Thank you so much.
 
 Thank you.
 
 Thank you for tuning in to Taking Healthcare by Storm, Industry Insights, with Quality Insights Medical Director, Dr.
 
 Jean Storm.
 
 We hope that you enjoyed this episode.
 
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 If you have any topics or guests you'd like to see on future episodes, you can reach out to us on our website.
 
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 So until next time, stay curious, stay compassionate, and keep taking healthcare by storm.