August 16, 2017
Ask the Chaplain: Carol Schneider PlainViews Staff
Toward Quality Spiritual Care in Long-Term Care Bruce Kalish
A Pilot Project for Outpatient Screening for Chaplaincy Services (April 14, 2015)
(Editor’s Note: This article was originally published on April 15, 2015).
Names of patients, doctors, and clinics have been changed to protect identities.
One morning in the outpatient clinic, a staff member quietly told me about Josiah, a young man in his 20s who was not responding well to the treatment regimens. He named the doctor who was working on the case and asked me to check on Josiah. After organizing other parts of the day’s work, I walked across the clinic and introduced myself.
Josiah’s feet were propped up in the extended chair and he hadn’t shaved for a few days. His weakened appearance was a stark contrast to his vivid blue baseball cap. An IV line with medications disappeared inside the top of his striped collarless shirt. Josiah introduced “Mom and Dad,” who appeared to be in their mid-fifties.
I was in the clinic as a second year resident chaplain with Indiana University Health at the Academic Health Center Hospitals in Indianapolis. My specialty is investigating, assessing, and developing chaplaincy in outpatient clinics. As residency began, our department also hired its first full time staff chaplain whose weekly hours are devoted to outpatient clinics.
The early days of our work were dedicated to constructing clinic profiles. We identify leadership, how patients are referred to the clinics, and days of the week when patient-flow varies from light to heavy. Our early discovery revealed there are approximately 50 outpatient clinics, open five days a week, through which more than 2,500 patients pass. Many of the clinics see patients with multiple diagnoses. Many patients have high levels of acuity. Josiah is in one of these clinics.
The clinic where Josiah is being treated meets one day a week and focuses on physician visits and infusions. He came to the clinic, as have many other patients, as a referral. Our research reveals almost all of the clinics in the Academic Health Center are places of referral for patients to consult with specialty providers.
As a research team part of our initial charge is identifying clinics whose patients present with challenging diagnoses. Our assumption is that this patient population would clearly benefit from the work of the chaplain. However, we soon learned there is more complexity than we first imagined, for example, even in an audiology clinic. Some patients come to the audiology outpatient clinic because their hearing impairment occurred at the time of a traumatic brain injury, which may add additional levels of issues to be addressed
A clear insight we carry out of the early days of discovery is that most of the outpatient clinics have patients susceptible to high levels of spiritual distress. An outpatient clinic in an academic health center often sees patients who are profoundly struggling from injury or disease.
Likewise, in a similar kind of linking, we became aware some patients come to the dermatology clinic and stay for many hours over the course of treatment. The dermatology clinics were not places where our chaplains traditionally worked other than making rounds. Yet, based on what we have discovered, academic health centers are filled with clinics where there is spiritual need.
A National Trend
Nationwide, patients with increasing levels of complex illnesses and injuries are reportedly being seen in outpatient settings. This is more than a mere increase in the number of patients. We are discovering chaplains do not need to delve very deeply in conversations with patients to find intense levels of loss and grief in these settings.
Additionally, at Indiana University Health some clinics anticipate more than doubling in physical size over the next year. While the clinic where Josiah is seen appears not to need more physical space at this time, there is discussion under way to add two days to their weekly schedule. Again, this growth is not isolated to our location alone
During any growth in outpatient settings, there is added stress for staff. These colleagues continue working in spite of construction zones and may have a sense of loss when their “personal space,” is disrupted by a new wall that was not there last week or when supplies are moved down the hall.
I was referred to Josiah by a staff member who asked me to meet him. Six months into the outpatient chaplaincy specialty assignment I have learned acceptance by outpatient clinics is a process in which staff relationships are of great value. This insight was confirmed during a recent interview with a chaplain whose work in outpatient settings spans more than a decade. He reported his work most often functions through the long-term staff relationships he has developed. During a recent interview he referred to the primacy of outpatient clinic staff as his working group to do spiritual screening for the thousands of patients who are seen in his institution’s clinics each day.
In some of our clinics chaplaincy appears to have quickly taken hold. We noticed that buy-in to our work seems to occur when a key leader becomes involved, supporting our colleague’s assertion that staff relationships carry great significance.
Key leaders in clinics may be physicians, nurses, pharmacists, and/or administrative staff. The key leaders may not have positional authority but are sometimes individuals already providing generalist spiritual care for patients and other staff members. For example, in one clinic the person scheduling appointments is also the first person patients meet when they enter. This front office worker offers regular referrals for chaplaincy.
I wondered how I was going to discern which outpatient, among the thousands seen each day, would potentially most benefit from seeing a chaplain. Given the large number of patients moving through the clinics I could not imagine how I would know which ones to see. Would I simply wander through a waiting room and talk with people who made eye contact with me?
Developing a Screening Tool
These questions led me into research for a screening tool in order to identify high priority patients. I read studies and journal articles that were available, and in their way each contributed to the five-part approach I am pursuing. Clinic staff was also helpful in its creation: as the screening tool was taking shape I asked various workers for their ideas. After one such conversation a staff member made the specific referral to Josiah. That same clinician said, “He may have a chronic condition. He’s probably not going to get better.” “Chronic condition,” was the language of the clinic. As I continued test driving early drafts of the tool, I discovered “chronic condition,” and other descriptive language translated well into various clinics.
Knowing staffs are capable of seeing many more patients than I could hope to meet, I enlisted their interdisciplinary assistance. Because of their cooperation a testable tool quickly took shape.
My hypothesis was that outpatient clinic staff are generalists capable of spiritual screening for a greater number of patients than chaplains could reasonably hope to meet. The strategy identified was that chaplains should enlist their help identifying patients with a high likelihood of spiritual distress. One anticipated outcome was that there would be an increase in the number of staff referrals to chaplains. As a result, I am setting into motion an institutionally approved 60-day pilot project of a spiritual screening tool to determine if it identifies patients who could benefit from the presence of the chaplain. It is a printed on a six-by-six-inch card and was given to each staff member in the clinic and placed on desks as well. It encourages the staff to do two things: first to contact the on-call chaplain for any identified immediate need and secondly, on the designated day of the pilot project to contact me directly when they identified a need. I have identified staff volunteers in four clinics to assist in leading the pilot program
Here are the five indicators I provided to staff, requesting that they make a referral to the chaplain whenever a patient meets one of the criteria.
The Five Indicators
Please contact the Chaplain:
The primary goal is to increase the number of referrals from the clinics. Additionally, I hope to open the cultural doors of clinics that previously referred to chaplaincy only in a crisis. To these ends I will be tracking:
I am grateful for the spiritual care and screening already taking place by staff in the interdisciplinary world of outpatient clinics. They function at a high level of spiritual and emotional awareness. I look forward to learning with them if this screening tool increases their effectiveness and increases referrals to chaplains.
Andrew Simkins, MDiv (Lincoln Christian Seminary), DMin (Trinity Evangelical Divinity School) is a long-serving pastor in the Christian Churches/Churches of Christ. Prior to beginning CPE at Tampa General Hospital in Florida, he worked as a church planter. Currently he is a second year CPE Resident with Indiana University Health, Indianapolis. He will be relocating to northern Indiana before the end of 2015.