The Need for Community Based Palliative Care Programs
Janet Bull, MD, MBA Principal Four Seasons Consulting Group
Most of the growth of palliative care has occurred in the inpatient hospital setting. Over 80% of hospitals offer palliative care services and many hospital administrators see the value of having robust programs. Community Based Palliative Care (CBPC) is a longitudinal model that integrates interdisciplinary care across inpatient and outpatient setting. CBPC programs differ significantly across the country in structure including team composition, eligibility, and standardization. Generally, if you’ve seen one CBPC program, you can be assured that you’ve only seen one and others will be different. There is a dearth of CBPC programs across the United States.
As we move in the direction of value-based care with the recently announced Alternative Payment Models (APM) for the Serious Illness Population, we expect a growth in CBPC. It will be important to have rigorous approaches to understand the most effective and efficient model of care. Palliative care models are heavily influenced by the reimbursement stream. Fee for service reimbursement generally favors models with Advance Practice Practitioners (nurse practitioners, physician assistants, and clinical nurse specialists) as these clinicians can bill via Evaluation and Management codes. In capitated models, nurses and social workers may have more prominent roles as team members since fee for service billing is not required.
CBPC programs address the needs of a seriously ill population by providing good symptom management, advance care planning, psychosocial and spiritual care, patient/family education, prognostication, and coordination with primary and specialty physicians. Comprehensive programs provide care in all settings (clinic, home, nursing facilities, and hospitals) so that as patients transition from one setting to the next continuity of care is provided by the team with 24/7 coverage. In addition, robust programs may have a telehealth component which includes remote patient monitoring and video conferencing. While quality metrics are still being defined in our specialty, programs need to track measures that matter to inform stakeholders on the impact of the services.
CBPC programs need to decide which patients are eligible and make sure scope creep does not occur. Do programs limit services to those who have a life limiting illness? Each organization will need to define who is appropriate for services, being aware that a low bar on entry may mean long length of stay patients who fall more into the chronic illness category. Eligibility according to the new APM will consist of:
(1) serious illness (2) frailty (3) healthcare utilization (hospitalization/ED visits).
Marketing and growth strategies are necessary to create awareness and stimulate referrals to a new program. Creating screening tools that help clinicians understand eligibility and educating the public by providing community forums will serve to raise awareness.
Mapping out administrative processes such as referral intake, insurance verification, obtaining medical records, entering patient information into an EMR, scheduling, and data tracking will be important to ensure consistency and efficiency.
Developing a risk stratification model will assist in making sure the sickest patients get seen quicker and more frequent. Palliative care patients differ in their needs and aligning care to match needs will safeguard the most effective care. In my experience of serving as the Principal Investigator on the CMS Innovation Project “Demonstrating the Value of Palliative Care,” I learned the importance of creating systems that ensure consistent, predictable care from patient to patient.
On Sept 30-Oct 1st, we will host our Developing a Palliative Care Workshop in Asheville, NC. We will share the tools and processes that we developed at Four Seasons to develop an efficient palliative care program. Come join us! For more information contact Lisa Massie at firstname.lastname@example.org.