Palliative Care Service is an interdisciplinary service for patients with advanced incurable illnesses, and their families, dedicated to relief of suffering and improvement of quality of life using a comprehensive approach. As the disease advances and it is evident that the patient is unlikely to survive, comfort measures become a priority. The goal of palliative care is to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies. Palliative care expands the traditional disease-model of medical treatments to include the goals of enhancing quality of life for patients and addressing the spiritual and social needs of patients and their families.

Within the New York City Health and Hospitals Corporation, Lincoln is among the top providers of Palliative Care Services. Lincoln Medical Center takes care of 160,000 emergency visits, 400,000 outpatient visits, and 30,000 inpatient discharges annually. Our consultative palliative care service has been active since 2004 and has grown to provide palliative services to more than 1,300 inpatients per year. Our training provides a wealth of clinical experience in the inpatient, outpatient ,long term care ,inpatient and outpatient hospice setting.

The Hospice and Palliative Care Fellowship Program at Lincoln Medical Center is fully accredited by the American Council of Graduate Medical Education - ACGME and provides comprehensive post-graduate training in all areas of the Hospice and palliative care. Lincoln Medical Center is located in the South Bronx (an area experiencing remarkable development and reinvigoration) and has long tradition of providing care to the poor and the disadvantaged in the City of New York .The Palliative care services Lincoln have been awarded certification as an Advanced Palliative Care Program by The Joint Commission (5/2012) and recertified again in 2014.

Chief, Palliative Care Services and Program Director Hospice and Palliative Care Fellowship Program: Puneeta Sharma,M.D.

Faculty
Dr.Vipul Shah,M.D.
Dr.Randy Seewald,M.D.
Dr.Rajindar Garg,M.D.
Dr.John Delfs,MD
Dr.Richard Dundee,M.D.
Dr.Huutcheon Gordon,M.D.
Dr.Paola Carugno,M.D.
Dr.Shefali Khanna,M.D.
Dr.Balavenkatesh Kanna,M.D.

Interdisciplinary Team Members
Anna Krakowski,RN
Ileana Dejesus,MST
Apeksha Desai,LCSW
Estela Aquino,MSW-Case worker

Carlos MorganFeld,Chaplain

Nicholas Nwagwu,Catholic Priest

Volunteers

The One year fellowship comprises of the following rotations:

1.Inpatient Consultative Service Experience
2.Outpatient Ambulatory Care experience
3.Long Term Experience
4.Hospice –Inpatient and Home Hospice Experience
5.Electives
6.Vacation

Block Diagram

The fellows’ inpatient experience will comprise a minimum of four months and will include a diverse patient population with significant social, supportive and symptom control needs.The acute care inpatient consultative service consults on patients with a very broad array of diagnosis pertaining to cardiology, pulmonology, Infectious disease, oncology, hematology, neurology, nephrology, geriatrics, surgery, trauma, rheumatology and gastroenterology. The consults arise from all across the institution medical / surgical floors, medical surgical intensive care units, emergency rooms etc. The service is consulted on patients with advanced and life-threatening illness to manage symptoms such as pain, dyspnea, nausea and vomiting, delirium, terminal agitation and restlessness, as well as complex discharge planning, defining goals of care, resolving ethical dilemmas and spiritual / social concerns. Apart from symptom management the team facilitates complex family meetings to establish goals of care, healthcare proxy, advance directives and non-resuscitation orders. The fellows will gain abundant experience in issues surrounding the withdrawal of life sustaining treatments for which we have developed an institutional protocol and management of symptoms at the end of life.The fellows will interact with the IDT and playing an instrumental role in assessing and coordinating the implementation of recommendations. Interventional pain experts are available to complement fellows learning on these strategies. The fellows will learn and provide bereavement therapy with the interdisciplinary team and facilitate debriefing on the acute care floor where a death occurs. The fellows will also learn about the acute treatment of palliative emergencies such as spinal cord compression, brain metastases, superior vena cava syndrome and hypercalcemia. Rotation through Pediatrics service will provide the fellows with an opportunity to learn the palliative aspects of pediatric care.The fellows will attend Ethics Committee meetings and share consultations with the Ethics Committee members (many overlap with palliative Medicine patients).Best practices have been compiled in the form of booklets, policies and literature syllabus to facilitate learning and online educational resources are readily available at the bedside. The fellows will hold Journal clubs periodically and participate in ongoing committees such as ethics, tumor board, organ donation and palliative performance improvement.

Lincoln has an established palliative care ambulatory clinic. This clinic expands access to palliative care services to patients that suffer from advanced debilitating illnesses that live in the community.Referral sources include patients known from inpatient consultation or new cases referred from other primary or specialty clinics. The diagnoses of the clinic patients include: advanced heart failure, cancer, neurodegenerative diseases, advanced lung disease, and end-stage renal / liver failure. The fellows ambulatory care experience is longitudinal throughout the year to facilitate continuity and evaluation of outcomes as the fellows will care for the patients throughout the trajectory of their illness from inpatient to clinic follow up and eventually hospice.The fellows are supervised by an attending physician in a one-on-one mentoring structure and with support of the interdisciplinary clinic team. The fellow will master the treatment of symptoms that are prevalent in the outpatients with life-threatening medical conditions. The fellows will learn about Opioid pharmacotherapy initiation, titration and rotation to best treat symptoms of pain and dyspnea. Other commonly managed symptoms include fatigue,anxiety,nausea,vomiting,,depression and constipation.In addition to medical management, patient and family education is paramount in the ambulatory care setting. Addressing Goals of care, advance directives, health care proxy, delivering of bad news and referring patients to comprehensive home care services. The fellows also learn to identify patients that need to be admitted to inpatient service for intensive pain and symptom management or those who need to be transitioned to home or inpatient hospice. Full interdisciplinary support is available on site during the ambulatory visit.

The long-term care experience will comprise a minimum period of one month (4 weeks) for each trainee and will take place at the Seton Elizabeth Pediatric Center.The fellow will conduct morning rounds with an attending physician, interdisciplinary rounds, and patient and family meetings to establish improved symptom control, address goals of care, establish health care surrogacy and advanced directives. All aspects of this rotation are mentored by an attending physician and the interdisciplinary team. During this experience the Fellows will be an integral member of the IDT, will present and discuss the patients with the team and faculty and will follow up the patients assigned to them. The fellows will participate in educational activities as well.

The fellows Home Hospice experience will take place through the VNS hospice program.The hospice experience consists of two and one half months rotation. A minimum of 25 home visits are expected to occur. The fellows will also rotate through VNS’s inpatient hospice units. The fellows will evaluate the patients under supervision of the attending physician and with other interdisciplinary team members, including registered nurses who are certified in hospice and palliative medicine, medical social workers and chaplains. The fellow will evaluate and discuss the cases with the IDT members and tailor the care plan based on this care setting. The team will execute the plan in parallel with the patient and the family goals of care. The fellow will complete a log of the home hospice cases which will be discussed as clinical vignettes based on the interventions and outcomes.The fellows will provide patient and family education on end of life; provide symptom control, psychosocial and spiritual support. The fellows collaborate with the hospices’ bereavement program.

Fellows have an elective rotation opportunity in an area of special interest. Elective rotations are available in Ethics, Oncology, Radiation Oncology, Emergency Medicine, Behavioral Health, HIV,Neurology, Geriatrics, Pain / Interventional Pain Medicine, Pediatrics, Physical Medicine and Rehabilitation, Critical Care, Cardiology and Pulmonary .The fellows will have a dedicated research component and Lincoln has an independent IRB (institutional Review Board) .Data and statistical analysis support is provided by our institution.

The program strongly encourages and supports the fellow’s culture of scholarly activity by active participation in organized clinical discussions, grand rounds, research activities, journal clubs and local and national conferences.Fellows are expected to participate and complete one project during the fellowship. The research director for all GME programs at Lincoln Medical Center will provide guidance and mentoring in learning principles of research methods,critical appraisal of literature, and designing a study. In addition, the fellows will also attend the on-line database search sessions conducted by the librarian to learn and understand the available databases and enhance research skills. All fellows are encouraged to participate in the Annual Lincoln Medical Center Research day and present their projects either by poster or oral presentations, if selected by peer review.

Grand Rounds weekly
Didactic sessions – monthly
Research Meetings monthly
Palliative Care Committee meetings – quarterly
Ethics Committee meetings – quarterly
ODN Committee Meetings – quarterly
Cancer Committee –quarterly
Pain Management Committee - quarterly
Tumour board weekly
Patient Safety Meetings – biweekly
Teach Back Rounds

Milestones are the competencies that fellows are expected to be proficient in during their fellowship.As the level of training progress,fellows are expected to do better.The evaluations are based on the following milestones
1.Patient Care
-Ability to gather and synthesizes essential and accurate information to define each patient’s clinical problem(s).
-Ability to develop and achieve comprehensive management plan for each patient.
-Ability to manage patients with progressive responsibility and independence.
-Demonstrate skill in performing and interpreting non-invasive procedures and/or testing.
-Request and provide consultative care.

2. Medical Knowledge –
-Possesses Clinical knowledge
-Knowledge of diagnostic testing and procedures.
-Scholarship.

3.Systems Based practice
- Ability to work effectively within an interprofessional team (e.g., with peers, consultants, nursing, ancillary professionals, and other support personnel).
- Recognize systems error and advocate for system improvement.
- Identify forces that impact the cost of health care, and advocate for and practice cost-effective care.
- Transition patients effectively within and across health delivery systems.

4.Practice Based Learning
-Monitor practice with a goal for improvement.
- Learn and improve via performance audit.
- Learn and improve via feedback.
- Learn and improve at the point of care.

5.Professionalism

- Professional and respectful interactions with patients, caregivers, and members of the interprofessional team (e.g., peers, consultants, nursing, ancillary professionals, and support personnel).
- Accept responsibility and follow through on tasks.
- Respond to each patient’s unique characteristics and needs.
- Exhibit integrity and ethical behavior in professional conduct.

6.Interpersonal and Communications Skills
- Communicate effectively with patients and caregivers.
- Communicate effectively in interprofessional teams (e.g., with peers, consultants, nursing, ancillary professionals, and other support personnel).
- Appropriate utilization and completion of health records.

Formative Evaluation

1. Performance of fellows is evaluated throughout the training. The evaluation includes six domains of clinical competence (patient care, medical knowledge, practice based learning and improvement and interpersonal and communications skills).
2. Structured clinical evaluations are conducted both on inpatient rotation and electives.
3. Medical records are reviewed for quality of data entry, accuracy of assessment, appropriateness of assessment and plan during each rotation. The review of medical records is included in the evaluation.

4. Fellows are evaluated online using New Innovations and their performance reviewed with them verbally as well. Fellows are required to review the online evaluation . The fellows have access to their online evaluations.
5. The Program Director evaluates the fellows semiannually.
6. Permanent records of the evaluations and counseling sessions for each fellow are maintained in the fellows file.
7. The fellows are evaluated by peers,patients and families and IDT team members.
8. The fellows also evaluate the faculty,program and peers.
9. The fellows also do a self evaluation.

Summative Evaluation

1. The program director prepares an evaluation of the clinical competence of each fellow annually at the conclusion of the fellows period of training in the program.
2. The summative evaluation stipulates the degree to which the resident has achieved the level of performance expected in each competency (i.e. patient care, medical knowledge, practice based learning and improvement, interpersonal and communication skills, professionalism, and systems- based practice).
3. A record of summative evaluation is maintained in the fellows file.
4. In the event of an adverse evaluation, a resident is offered an opportunity to address a judgment of academic deficiencies before Clinical Competence Committee.

Fellow evaluation of the faculty members and the program

1. The Fellows are asked to evaluate the attending physician confidentially. The evaluations are reviewed by the program director and used for faculty member counseling and for selecting faculty members for specific teaching assignments.
2. The Fellows must evaluate the program at least annually. Specifically the quality of the curriculum and the extent to which goals and objectives have been achieved must be assessed.

The fellowship program seeks to ensure that the fellows develop skills, knowledge and attitude necessary for a career in Hospice and palliative care . On graduation the house officer is expected to possess detailed knowledge and practical skills to pursue successful careers as hospice and palliative care specialists.

The principal teaching methods in Hospice and palliative care fellowship program involve a combination of individual patient based encounters, case discussions and a series of didactic conferences. In each individual patient encounter, there is a detailed discussion with an attending physician. The didactic conferences similarly utilize a patient based approach to integrate the basic sciences of pathophysiology with clinical presentations and an evidence-based approach to diagnosis and management. It is our strong belief that this patient-based approach utilizing both individual and group teaching maximizes our educational efficacy.

Medical Grand Rounds
Medical Grand Rounds are held weekly by prominent guest speakers, covering a wide range of important topics in Internal Medicine and its subspecialties.
Journal Club –conducted monthly during didactic sessions
Morbidity and Mortality Conferences
This conference is held monthly to discuss deaths and problematic cases, identified by the ACMR, attending staff, or through the CQI process. The cases are presented by the PGYII or PGYIII who was not involved in the care of the particular patient in order to ensure an in depth and objective discussions of the issues identified. The conference is attended by the medical house staff, medical attendings staff, the Program Director and Chief of Service. The ACMR is responsible for moderation of the case discussion.
Tumor Board
This is a combined medical-surgical conference held every week in which surgical, medical and radiologic management of cancers is reviewed.

Lincoln Medical Center is one of the relatively few facilities in the United States with fully computerized electronic medical record. The Health Care Information and Management Systems Society (HCIMMS) awarded our institution the prestigious Davies award in 2006 (The Davies Awards recognize excellence in the implementation and use of health information technology (IT) for health-care organizations, private practices and public health systems).


All essential activities are computerized – Electronic H&Ps, progress notes, clinic notes, discharge summaries, consults, computerized ordering of investigations and medication orders, documentation of vital signs, medication administration, social services and dietitian notes etc. All radiology and imaging services are also completely computerized. Radiology investigations and electrocardiograms are available for review on all computers throughout the institution.


In addition to numerous stationary computers, all areas are equipped with wireless devices that have the same functionality as the wired stations.


All staff has super fast internet access to numerous sources of information, including UpToDate, Ovid, access to full text articles of many textbooks and journals, Micromedix and other drugs databases.


The department has a well equipped conference room with all necessary electronics to facilitate the different conferences and presentations as well.

Applications for Fellowship in Hospice and Palliative Medicine are submitted exclusively through ERAS(Electronic Residency Application service).www.aamc.org
Selected applicants are invited for interview. Every applicant invited for interview meets at least two of the members of the resident selection committee. The applicants are given a tour of the hospital and meet with members of the housestaff. Once the interviews are conducted, the division prepares a rank order list and the latter is submitted to the NRMP. I. There are Four ACGME approved Fellowship positions for the Hospice and Palliative care fellowship Program.
II. All of the available positions are filled through the NRMP.
III. All selected and matched fellows receive contract letter, a copy of which is returned to the division of Hospice and Palliative Care .The incoming housestaff receives mandatory orientation organized by the GME 10-14 days before the official beginning of their training. The employment contract is in accordance with the agreement between the CIR (Committee of Interns and Residents) and the HHC (Health and Hospital Corporation).

Dr.Puneeta Sharma ,MD
Chief of Palliative Care Services
Program Director Hospice and Palliative Care Fellowship Program
Lincoln Medical and Mental Health Center
Division of Hospice and Palliative Care
234 E,149th street
Bronx NY 10451
Phone 718-579-5280
Fax-718-579-4836
Email-puneeta.sharma@nychhc.org

Ms.Nilsa Velazquez
Hospice and Palliative Care Program Fellowship Coordinator
Lincoln Medical and Mental Health Center
Division of Hospice and Palliative Care
234 E,149th street
Bronx NY 10451
Phone 718-579-6679
Fax-718-579-4836
Email Nilsa.Velazquez@nychhc.org