At a Glance
- Palliative care is an essential component of care delivery models designed to address healthcare reform mandates. However, even after years of existence, these services continue to be unknown, underutilized, and/or misunderstood.
- Often only associated with care at the end of life or confused with hospice, interdisciplinary palliative care teams provide medical care coordination for patients’ severe, complex, and/or chronic conditions, longer-than-anticipated length of stay, and/or psychosocial difficulties, regardless of age or prognosis.
- Organizations that are developing population health initiatives should consider pursuing a strategy incorporating palliative care.
- The palliative care process enhances patient satisfaction, quality of care, and outcomes while reducing costs.
Healthcare initiatives today are focused on improving care coordination and enhancing quality of care while reducing the cost of that care. Many approaches are being evaluated, but one essential and effective process remains in the shadows: the use of palliative care to improve value.
Experienced palliative caregivers continue to be underutilized and/or misunderstood. Palliative care originated as comfort care. However, over the past several years, the role of palliative care teams has evolved to include medical care coordination that addresses some of the major issues being discussed with healthcare reform.
Often associated with “end-of-life care,” interdisciplinary palliative care teams also may be used to manage care for patients with chronic conditions, serious acute illnesses, longer-than-anticipated length of stay (LOS), or psychosocial difficulties, as well as those who experience major complications.
In an era of reform, today’s healthcare leaders should more fully understand what palliative care is designed to achieve; the barriers to wider adoption; and the financial, medical, psychosocial, and satisfaction benefits that palliative care can provide for hospitals and patients.
Palliative Care Defined
There are various definitions for palliative care. The Center for Advancement of Palliative Care (CAPC) defines it as “specialized medical care for people with serious illnesses”. Its goals are to improve the quality of life for patients and their families and to provide an extra layer of support by promoting a team focus to patient care. An effective palliative care program fosters closer and clearer communication among clinicians, patients, and their families. By establishing and focusing on clear patient care goals, cost savings are achieved, patient satisfaction is increased, and LOS is reduced—particularly LOS in critical care areas.
There are a number of barriers to wide adoption of palliative care services.
Lack of public awareness. Many in the public sector remain unaware that palliative care teams exist in hospitals, or they perceive palliative care as “inpatient hospice.” By informing and educating patients with chronic, complex, critical illnesses and their families, upon admission, that palliative care services are available, hospitals can better promote streamlined, effective medical delivery. Hospitals and health systems should strive to increase public awareness of these programs to assist families in knowing when and why such services should be requested.
Limited scope. Some organizations view the use of palliative care as being appropriate only for end-of-life patients or as a means to reduce LOS. Organizations often do not understand how effective the palliative care process can be in controlling costs of complex cases, managing patients with chronic conditions, and coordinating medical care in acute care settings, both inpatient and outpatient. Using palliative care presents an opportunity for growth toward establishing patient goals and coordinating medical care across the care continuum: inpatient, outpatient, home care, skilled nursing, or rehabilitative facilities. Screening newly admitted patients for palliative care needs or identifying readmitted patients who have previously received palliative care, especially in the emergency department, results in higher patient satisfaction, better medical outcomes, and reduced LOS.
Reluctance of primary care physicians. Although each patient’s well-being is at the heart of a primary care physician’s focus, these physicians often simply cannot coordinate schedules to speak at length with all family members, guardians, or powers of attorney regarding important care decisions. Palliative care teams offer a vehicle for critical communication among patients, families, primary care physicians, and consulting clinicians. A defining characteristic of palliative care staff is their strong sense of teamwork.
Conflicts may arise if palliative care teams are perceived as questioning or taking over the primary care physician’s decisions. Once familiar with the goals and methods of palliative care delivery, physicians typically realize the benefit of having strong facilitators for decision making with their patients and patients’ families. Introducing palliative care to assist with managing patient care goals should be equivalent to referring patients to specialists who can manage specific elements of their care.
Lack of standardization. Since 2000, the number of palliative care teams within hospital settings has increased almost threefold, from roughly 600 to more than 1,600 today (“Growth of Palliative Care in U.S. Hospitals: 2012 Snapshot,” Center to Advance Palliative Care). Despite this increase in palliative care programs, the effective use of their processes continues to lag.
Among palliative care programs, there is a lack of standardization with regard to how teams are structured and operated. Even multifacility organizations often lack a corporate structure that drives fully integrated, systemwide palliative care departments. For example, variances often are seen in billing of time, staffing, referrals, roles and responsibilities, and reporting.
In the case of billing of time, some departments state they bill for their time, while others do not.
With regard to staffing variances, clinical complements often vary among hospital teams, even within the same corporation. Some use nurse practitioners; others include staff nurses. Most teams incorporate a physician and a hospital chaplain. Some teams include dedicated social workers, while others share social workers with case management departments. Some teams include pharmacists.
Regarding referrals, many hospitals employ a “pull” strategy that requires a primary care physician’s written order before palliative care can be introduced to a case. Other organizations allow staff nurses to initiate referrals or may use a screening tool to identify patients who would benefit from palliative care team coverage.
Roles and responsibilities for palliative care often are defined differently, as well: Some organizations have specific delineated lines between case management and palliative care, while others struggle with clear hand-offs in roles between case managers and palliative care nurses.
In the area of reporting, various teams may report through different channels, including nursing (chief nursing officer or vice president of nursing), case management, and medical directors.
Most critical to full adoption of palliative care in hospitals and health systems is the ability to move past internal politics that could hinder streamlined integration with standard patient care.
There is ongoing discussion around optimal reporting structures for palliative care, including whether palliative care should be integrated with case management. Although economies of scale could be achieved via integration with case management, there could be significant risk to the effectiveness of palliative care teams. Palliative care focuses on medical and emotional management of chronically ill or complex patients, while case management oversees the effective and efficient movement of patients through the healthcare continuum. Palliative care teams’ efforts and outcomes are typically subjective in nature; case management results are more definitive and quantifiable. Integrating palliative care and case management can offer wider exposure of palliative care services, but clear guidelines and parameters are needed to ensure the integrity and focus of the distinct services are kept intact.
Although classified as a non–revenue-generating service, palliative care hours can be billable, and the financial benefits to hospitals are shown through cost savings and cost avoidance. A 2008 study published in the Archives of Internal Medicine compared direct costs of patients who were cared for by a palliative care team with direct costs of matched patients who were not covered by palliative care—defined as treated with “usual care” (Morrison, R.S., et al., “Cost Savings Associated with U.S. Hospital Palliative Care Consultation Programs,” Archives of Internal Medicine, Sept. 8, 2008). The study, which analyzed data from eight hospitals, found that the use of palliative care provided a weighted average yearly cost savings of more than $7.5 million. This example reflects conservative savings, because it is based on costs during the years 2002 to 2004. It also does not include indirect cost savings, represents a sampling of palliative care patients, and does not take into account savings from unwanted or unnecessary procedures.
The 2008 study disclosed that the use of palliative care resulted in significant reductions in pharmacy, laboratory, and intensive care unit costs compared with patients who did not receive palliative care:
- Among palliative care patients who were discharged alive, hospitals saved $279 in direct costs per day and almost $1,700 in direct costs per admission per palliative care patient.
- Among palliative care patients who died, the corresponding savings amounted to $374 and more than $4,900, respectively.
- Savings included significant reductions in pharmacy, laboratory, and intensive care costs.
- The authors concluded that an average 400-bed hospital seeing 5,000 patients a year could realize annual net savings of $1.3 million by implementing a palliative care program.
Another study performed using Medicaid patient data for four New York hospitals from 2004 to 2007 showed that, on average, patients who received palliative care incurred $6,900 less in hospital costs per admission than patients who received usual care. Cost reductions per admission included $4,098 for patients discharged alive and $7,563 for those who died in the hospital (Morrison, R.S., et al, “Palliative Care Consultation Teams Cut Hospital Costs For Medicaid Beneficiaries,” Health Affairs, March 2011).
Although the structure of palliative care teams is not standardized among hospitals, the exhibit below shows a base sample of personnel needed. The sample salaries included in this exhibit illustrate that, for a modest investment, a hospital can achieve ROI with even a small volume of patients seen.
According to these figures, the investment of qualified personnel more than pays for itself in the cost savings achieved.
Patients receiving palliative care have shown physical improvement as patient symptoms are addressed early, leading to longer survival as well as higher quality of life.
A study at Massachusetts General Hospital, a Harvard University teaching hospital, followed 151 patients with non-small-cell lung cancer.
Fifty percent of patients received palliative care along with standard treatments; 50 percent received standard treatment alone; about a third of the patients had no cancer-related symptoms when they first received palliative care; and 94 percent of patients were fully ambulatory. Although the patients experiencing palliative care received less aggressive end-of-life care than the standard care patients, they lived 2.7 months longer, on average (Palliative Care: Surprising Benefits from an Underused Therapy, Harvard Medical School, Harvard Health Publications, April 1, 2012).
Palliative care programs significantly reduce pain levels, providing comfort and peace of mind. According to CAPC, numerous studies also show palliative care controls fatigue, anxiety, breathlessness, nausea, depression, constipation, and other sources of symptom distress, leading to enhanced physical outcomes.
Hospitals are in the business of healing, and there is a point where curative care is no longer realistic. Healing is not just the curing of disease; it also involves holistically addressing the physical, psychosocial, emotional, and spiritual wellness of a patient. Palliative care provides a service to address the holistic care of patients and their families, especially when chronic or severe conditions are not curable or resolvable.
Awareness Is Critical
Palliative care teams provide more than just comfort or end-of-life care: They assist patients and their families in establishing clear, realistic patient-care goals based on the specific needs in each individual case, coordinating medical care delivery among myriad caregivers, and providing psychological and emotional support throughout care delivery. Their effectiveness extends to many chronic, critically ill, and complex psychosocial cases, regardless of diagnosis or prognosis. Now is the time to bring palliative care to the forefront of healthcare discussions as a process to enhance patient satisfaction and provide cost-effective, high-quality care. Enhancing public awareness is critical to program expansion and broad-scale availability of palliative care services.
Donna Verret is principal, Novia Strategies, Poway, Calif. (firstname.lastname@example.org).
Rose M. Rohloff, RN, is executive director, The PARC Group, LLC, Chicago (email@example.com).
Publication Date: Friday, March 01, 2013