Erin Kross

Welcome to Collective Conversations, a series of discussions aimed at highlighting people and groups working to improve health through better health care systems. 

Hear from Dr. Erin Kross and her research experience in palliative care deploying a communication priming tool, the Jumpstart Guide, within outpatient and inpatient settings. She shares great insights and I am excited for you to listen in.

Joy Lee: There are a number of systems issues that could be addressed in the area of palliative care. What led you to want to focus on communication priming for clinician and patients in different settings as a focus area?

Erin Kross: Palliative care is a very broad field and there are lots of potential systems issues to be addressed. At the Cambia Palliative Care Center of Excellence, which I co-direct, we’ve really taken a broad lens to thinking about palliative care in general. We have initiatives that are focused on education, clinical operations, quality improvement, research, and at the center, we focus on both primary palliative care and specialty palliative care. Primary palliative care is really the primary care skills that all clinicians who care for patients with serious illness should have. And so, we selected this communication priming intervention as one tool to try to improve the communication that occurs between all clinicians who care for patients with serious illness and their patients. Because we feel that having these conversations about what is most important to patients, what their goals of care are should be standard of care, and yet, are not consistently done across our health system or many health systems. So, this felt like a prime opportunity to improve the care that’s delivered to patients within UW Medicine.

JL: You recently published findings from a randomized control trial in outpatient settings about a communication priming guide, the Jumpstart Guide. It seems like it was a systems intervention with a patient-centered design – two things that aren’t at odds but, unfortunately, are not always aligned. Can you walk us through the rationale and process of undertaking this type of work?

EK: The whole idea behind the Jumpstart Guide is to get clinicians and patients talking to one another. Talking about what’s most important to patients. What really they value the most. To help start to frame treatment plans that can be aligned with what an individual patient’s goals of care are. The Jumpstart is a communication priming tool. We create a one-page document that has some personalized data about patients and some general tips for clinicians about how to have a goals of care discussion with a patient with serious illness, how to get the conversation going, and some specific communication prompts to try to improve that conversation.

And the Jumpstart intervention has gone through several different iterations over many years. The randomized trial that you are referring to did take place in the outpatient setting. We enrolled clinicians who are caring for patients with diverse group of chronic serious illness randomized clinicians and then their patients to either receive the Jumpstart intervention or be part of a usual care arm. In that version of the study, we first surveyed patients to understand their own barriers and facilitators to having goals of care conversations with their clinicians. And then create tailored Jumpstart forms based on that information we received from patients and provided Jumpstart forms to both patients and their clinicians. And so, I think to your point about it being a systems intervention but really a patient-centered design, we leaned on that input from patients to help tailor the Jumpstart Guide. And we did show that conversations increased from about 30% in the usual care arm to about 70% in the intervention arm – so an impressive improvement. And patients also rated the quality of those conversations to be higher in the intervention arm. The challenge of that study design however is that you can imagine it’s very labor-intensive and doesn’t lend itself very easily to a wide systems level intervention across an entire healthcare system. And so that’s really led to some refinement of the Jumpstart and some new ways that we are looking to test it across our healthcare system.

We have most recently adapted the Jumpstart to instead of relying on survey data from patients to tailor the guide to pull patient-specific details that we can get directly from the EHR to tailor a guide that can be given to clinicians. We’re currently testing that version of the Jumpstart Guide in the inpatient setting. Dr. Randy Curtis and Dr. Ruth Engelberg lead two trial study in the inpatient setting where we’re looking at this more pragmatic approach to delivery of a Jumpstart to a wider population of patients, no longer needing to enroll patients ahead of time and get their tailored surveys, but rather leaning on data that we can get from the EHR.

JL: Can you tell us more about the input from patients that you received to create these really organized communication guides?

EK: As I’ve mentioned in the prior outpatient trials, we surveyed patients first to use their information to tailor their guide. For this more pragmatic design, we’re taking a different approach and we’ve been using a human-centered design approach to tailor the Jumpstart for these more pragmatic trials. So, we’ve done this, we’ve completed this, we’ve published on this process for how we adapted the Jumpstart to the inpatient setting. And the human-centered design took in a lot of different stakeholders’ perspectives – clinicians, expert communicators, and patients and family members as we adapted the Jumpstart Guide for that study. And that’s a process that we’re taking on for future adaptions of the Jumpstart Guide. We were really interested in talking to patients and family members as we sort of prototyped and think about what the next version of Jumpstart will be.

JL: What is the next step in scaling up or expanding use in different care settings?

EK: Yes. We’re very excited about the opportunity of having this more pragmatic approach to deliver Jumpstart more widely across our healthcare system. And so, I mentioned Dr. Curtis and Dr. Engelberg are currently leading an NIA funded trial in the inpatient setting. We are now looking for opportunities to take Jumpstart back to the outpatient setting because you can imagine that the types of goals of care conversations that patients have with their clinicians vary depending on the setting – both are important, but they’re different. And in the outpatient setting, patients are often able to have these conversations when crisis is not occurring and with clinicians that know them better than the clinicians that take care of them when they are at the hospital. So, our next steps in addition to completing the inpatient trials that are ongoing is to try to get the Jumpstart back to the outpatient setting in this new form that we have, which is pulling data from the EHR and being delivered to clinicians only to prompt these conversations.

We have a pending grant from the National Institute of Aging to test Jumpstart in the outpatient setting for patients with Alzheimer’s disease and related dementias, and that I think will be our next funded project*. And we’re also looking for opportunities to test Jumpstart in a broader population of patients with chronic and serious illness.

JL: What recommendations would you have for others who want to use discussion guides to improve some aspect of care delivery or systems?

EK: I think that one of the things that our research team has done really well when investigating Jumpstart as a communication priming tool is to think about aspects related to the intervention. Most of our research grants have aims written in that look at implementation outcomes. So, it’s not enough to just say we have this intervention and we’re going to deliver it and we’re going to see what the outcomes are. We’re really interested in learning about how the intervention is implemented within a healthcare system. What do patients think about it? What do clinicians think about it? Are we delivering the intervention to clinicians in the right way in a way that they find useful and helpful? How often are clinicians actually using this tool that we provide to them via email or through Epic? So, I think that thinking about aspects of how the intervention is actually delivered, used, and implemented is a really important aspect of learning how we can do this better.

JL: Thank you again for sharing this information about your work and we’re excited to hear more about where Jumpstart heads and the next iterations, and hope to have you back again.

EK: Thank you so much for having me.

*Since the time of this recording, Drs. Kross and Curtis received the R01 award from the NIA to begin this five year study.