Integrating palliative care improves pain management and reduces length of stay in a comprehensive lifespan sickle cell center

Abstract

Abstract Introduction: Sickle cell disease (SCD) is the most common monogenic disorder in the United States, affecting over 100,000 people (Hassel K, Am J Prev Med 2010). Pain is the hallmark of the disease, and vaso-occlusive episodes (VOCs) account for 84% of hospitalizations in adults with SCD, significantly affecting quality of life and healthcare utilization (Cronin et al, Hematol 2019). The average length of stay for all ages is 5 days, with a 33% 30-day readmission rate, costing over $800 million dollars per year (HCUP2016). Despite evidence that palliative care (PC) interventions help improve quality of life and reduce healthcare utilization (Horton JR et al, J Palliat Med 2016), a review of almost a million hospitalizations from 2008-2017 found PC was consulted in fewer than 1% of admissions (Nwogu-Onyemkpa E et al, BMJ Open 2022). Cleveland Clinic Sickle Cell Medical Neighborhood (SCMN), established in 2020, provides comprehensive lifespan sickle cell care for people with SCD in northeast Ohio. The Medical Neighborhood includes medical and pediatric subspecialties but did not initially include palliative care, individualized pain care plans, or guided inpatient pain management, leading to an average length of stay exceeding 9 days. This quality improvement project aims to integrate PC into the SCMN to provide guided inpatient and outpatient pain management and reduce the length of stay for our sickle cell patients. Methods: Cleveland Clinic Department of Palliative and Supportive Care collaborated with the SCMN to establish an integrated care model. Hospitalists, primary care clinicians, hematologists and PC teams worked together to evolve from ad hoc inpatient PC consultations to a structured program. Key interventions included:Embedding a PC consult and a hematology consult trigger into the inpatient SCD hospital admission order set.Establishing outpatient PC followup for outpatient pain management recommendations.Developing and implementing Individualized Care Plans (ICPs) for high utilizing patients. Results: PC was incorporated into the SCMN in February 2024 to help with outpatient pain management and develop ICPs in our high utilizing patients. In April 2024, the inpatient PC and hematology consult trigger was activated in the inpatient SCD hospital admission order set, and ICPs for high-utilizer patients were implemented in November 2024. From April 2024 to March 2025, enrollment in the SCMN grew from 190 patients to 231. In that time, mean annualized hospitalization rate per patient was reduced from 1.4 to 1.3 admissions per patient, and the mean inpatient length of stay (LOS) for adults with SCD decreased from 9.1 to 3.2 days. Patients received care across multiple care settings, including a quaternary care center, community hospitals, and outpatient clinics. Regular interdisciplinary care meetings built confidence among PC and SCMN clinicians, fostering improved opioid stewardship and the implementation of shared decision-making protocols. Conclusions: Incorporating a PC team into a comprehensive sickle cell care center significantly reduces inpatient length of stay and improves outpatient pain management in a historically underserved population. This model demonstrates the value of interdisciplinary collaboration in improving healthcare utilization. Further efforts will examine associated cost savings and broader applicability.