Wednesday, March 11, 2015

The Evolving Role of Hospice and Palliative Medicine Leadership

As hospices and palliative care services evolve into accountable palliative care organizations with greater scope and influence over late-life care within their communities, a "new" physician executive role is emerging along the career path for HPM physicians. This role is broader than the traditional senior medical director or chief medical officer positions, and is progressing toward what we refer to as the "chief community palliative care officer".

These physician executive positions have proven to be instrumental in shaping late-life care practices by applying management competencies to:

-build and sustain relationships that evolve into community-wide palliative care networks

-disseminate throughout a community the use of metrics and evidence-based practices to hold practitioners to high standards of performance

-inspire referring physicians and HPM medical staff members to meet clinical outcomes and family satisfaction metrics

-envision and stimulate a change process that coalesces the community around new models of late-life care

Daunting challenges, to be sure.  As hospice executives and HPM physicians (and nurse practitioners) come to grips with  rules around eligibility and face-to-face recertification requirements, we would all do well to remain mindful of the strategic leadership objectives that will ultimately determine how successful we are in transforming late-life care in the US. We've seen the importance of HPM leadership in exemplar communities across America (some of which have featured in this blog) -  assembling the right mix of intellectual capital, at the right time (what we refer to as bellwether practices) becomes one of the must-have competencies of late-life care organizations.

Friday, February 20, 2015

Choosing Where To Retire Based On Late-Life Preferences

In an earlier post (read here) , I wondered if ratings of retirement towns and cities would eventually include information about their culture and practices around late-life care. Our study of "retirement cities" and their palliative care practices, using data drawn from the Dartmouth Medical Atlas, reveals that a huge distance separate better performers from lesser performers.

One community recognized widely among desirable retirement towns is Asheville, North Carolina. Turns out that Asheville is among the better-performers in late-life care.Residents of the Asheville region are 20% less likely to die in a hospital than the state average, and 30% less likely during their final six months of life to spend time in an ICU. Asheville's overall results have earned an A grade in the DAI Community Palliative Performance Grading, placing it among exemplar communities.

Sarasota, Florida is another "retirement" community scoring high in the DAI Community Palliative Performance grading. We conclude, upon further analysis, that these exceptional results don't happen by accident. Rather, they are produced by design, including the presence of palliative medicine physician-champions and a large hospice with close relationships with the community's health care providers.

Wednesday, February 18, 2015

Accountable Palliative Care Organizations - Best Hope to Improve Late-Life Care?

The days of open access for hospice, regrettably, have yet, with few exceptions, to come to fruition. The hospice industry in the US has been taken over by single-purpose organizations who are adept at "enrollment management" - that is, identifying both low-cost patients who would be financially attractive (and encouraging these patients to enroll on the hospice benefit) AND high-cost patients who would be financial drains (and discouraging those patients from enrolling). And it is difficult to fault these organizations, as their managers are merely responding to the financial incentives built into the hospice benefit by Medicare and other payers.

 We are faced with the paradox that introduction of the hospice benefit has improved access to better end-of-life care, yet at the same time has come to define end-of-life care, and by extension, palliative care. It's similar to how 28 days of inpatient care came to define alcohol and drug rehab treatment merely because that's what the payers would cover.

How can we see further improvement in end-of-life care? By reorganizing how end-of life care is provided, so that "accountable palliative care organizations", of which hospices are an integral but not the whole piece, are the center of late-life care within health systems and communities.
Some of you have asked about the characteristics of APCOs. First, they are virtual enterprises, that is to say, unincorporated structures, that are 'sponsored" by a community-based health care organization, most often either a hospital (health system) or hospice.

Simply, the key elements of an APCO are:

  • A Chief Palliative Care Officer (full-time physician credentialed in hospice and palliative medicine) accountable for palliative care services across all settings,
  • Integrating tools that encourage dissemination of knowledge and promote collaboration across settings and disciplines (for example, APCOs have found Physician Orders for Life-Sustaining Treatment (POLST) to be just such an integrating tool),
  • Multiple sources of revenue (hospice, home health, physician services) that offer opportunities for cross-subsidization of individual patient care and economies of scale on the expense side.

How one constructs an APCO depends on many factors, mostly related to the amount of "palliative intellectual capital" already in place at the sponsoring organization.

Tuesday, February 17, 2015

Hospice and Palliative Care - Are We Giving a Mixed Message?

Is there a difference between Hospice and Palliative Care?
Some say this is merely a matter of semantics, so why bother? I'd like to offer my thoughts, as someone who has been involved with "hospice" since the mid-80s.

The reason why this is an important issue is quite simply because it matters to the public. It matters because use of the terms together suggests to some that they are synonymous, and to others that they are distinct. I submit they are neither the same nor distinct.

In its earlier days, hospice described a concept of care. Over the past quarter-century (once hospice became covered by Medicare as a benefit), it has come to describe (define?) an organized and highly prescribed system through which end-of-life services are provided. The practitioners of these services have taken on, perhaps out of convenience, the name of hospice into their titles.It's analogous to surgeons describing themselves as Operating Room and Surgical Medicine physicians, or ER docs referring to their specialty as Hospital and Emergency Medicine. I'm sure you could think of other analogies.

Those receiving palliative care do so in many settings (home, hospital, SNF, outpatient office, assisted living, hospice inpatient unit) while utilizing various health benefits/coverages (of course the hospice benefit but also home health benefit, physician services, i.e Medicare part B )to pay for these palliative services. In other words, palliative care is provided by a host of professionals to patients during "late-life". Some, but certainly not all of these patients use the hospice benefit (provided by Medicare and most private health insurance plans) to cover the cost of palliative care.

A recent study commissioned by the Center to Advance Palliative Care found that much of the public did not understand or was not familiar with the term palliative care. But it's not only the public who is confused. The specialty's own practitioners are confused, and are unintentionally adding to the general misunderstanding. On the website of a prominent Midwest medical center, a reader comes across this comment,“Palliative care and hospice are different,” explained the medical director of the palliative care service.  “Hospice is restricted to people who have a prognosis of less than six months to live. However, palliative care does not have that restriction because it does more than just help people at the end of their life.” What does a patient, or family member do with such information? For that matter, what does a prospective referring source (a discharge planner, or family physician) do with that information?

The question we in the field should be asking is how we can best increase access to palliative care. If some of that palliative care is provided by a licensed hospice, reimbursed by the hospice benefit, fine. If some of the care is provided by a hospital, or a SNF, reimbursed by the physician services benefit, all to the good. If some of the palliative care is provided by a home health agency, reimbursed under a home health benefit, all the better. What matters is that a patient (and family) receive timely access to palliative care and its practitioners.

More on this subject in future posts. in the meantime, I invite your feedback.

Monday, January 12, 2015

Valuable Experiences of a Hospice and Palliative Medicine (HPM) Fellowship

When asked by HPM fellows what experiences one should seek to strengthen skill set, I'll recommend the following (a currently practicing HPM physician would also do well to gain these experiences):

-Actively participating in any end-of-life care coalitions in the community, and if one doesn't exist, assemble several HPM practitioners in the community to start a coalition. Coalitions working to change the model of  late-life care in the community are a common element in those regions known for their exemplar practices in late-life care.

-Engaging in initiatives aimed at reducing late-life care clinical variation within the community. These often take the form of  interdisciplinary work groups standardizing protocols or tools, either within a palliative care organization or the community at-large.

- Joining with other clinicians in institutional or community-wide intiatives to ensure safe transitions across settings and reduce hospital readmissions. There is a strong palliative care component in prevailing readmission  reduction programs, among those the commonly used Interact (Interventions to Reduce Acute CareTransfers) tool.

The skills and competencies gained from these experiences will hold an HPM physician in good stead in securing the most attractive professional opportunities emerging in the HPM sector (see this previous post  for more on the emerging role of HPM physicians).

I'm curious to hear from current and recent fellows about what experiences you've found most valuable.

Tuesday, March 26, 2013

Stranger than Fiction: SDHIPC Demise a Painful and Difficult Story to Understand

Posted by Shelley Sansbury, health care strategist

This is a difficult story for everyone involved, most certainly the patients and their families and physicians, as well as many hundreds of ex-employees and volunteers, donors and creditors.

It is a difficult story to report…like chasing chickens…particularly when transparency doesn’t appear to be a value embraced by the current regime. Local reporters must rely on the Freedom of Information Act to get past the obfuscation of the spokesman for the distressed organization.

How and why a hospice practically venerated as an industry leader after 35 years could disintegrate in a matter of months is more than a little perplexing. Here, in broad brush strokes, are a few of the major milestones associated with the rapid devolution of one of the largest and most respected hospice and palliative care organizations in the U.S.


Jul 1, 2010 –
                        The Board Chairman announces the appointment of a former public relations and fundraising functionary with the San Diego Hospice Foundation as President and Chief Executive Officer, succeeding Jan Cetti who has retired after 14 years at the helm of SDHIMC

Feb, 2011 –
            A team of 8 Medicare auditors spend 5 days on site reviewing 149 charts of patients admitted to service between 1/1/09 and 11/30/10, the results of which are, more than 2 years hence, yet to be disclosed, according to CEO Pacurar.

Sept, 14 – Sept 22, 2011 –

            A team of 4 surveyors arrive from the CA Dept of Public health arrive to                     conduct a routine Medicare re-certification survey. Initially 20 patients are  sampled. The survey which lasts 8 days includes home visits to 5 patients.  Nine deficiencies are cited including agency leadership for failure to assure reporting of Adverse Events including errors in the use of a Computer-aided Drug Delivery (CADD) pump resulting in a patient  receiving 5x the prescribed dose of morphine sulfate. In the course of the survey the agency spontaneously reports two additional similar recent events. The survey sample is amended to include these patients. According to the survey:                                              


                        The facility failed to implement immediate corrective actions to prevent                                  reoccurrence of CADD pump (continuous ambulatory delivery device                                        used to deliver narcotic analgesia) narcotic overmedication incidents,                                             after the first incident on 8/7/11. Within 40 days of the first incident, 2                                      more patients were involved in CADD pump narcotic overdose incidents.                                         The Vice President of Inpatient & Nursing Services and the Manager of                                     Pharmacy were notified of an Immediate Jeopardy on 9/16/11 at 5:05P.M.


  Less than two hours after the Immediate Jeopardy designation, the Vice President of Inpatient & Nursing Services.presents a 7-point plan of  correction. Surveyors respond favorably and the Immediate Jeopardy is abated at 6:40 P.M.

Dec 12, 2011 -

            State surveyors return to verify implementation of the Plan of Correction

Jan 12, 2012  - 

            A senior official of the Survey and Certification Division of Medicare                                       writes:


Contrary to your allegations of correction, however, this resurvey, completed on December 12,2011, documented your continued noncompliance with Federal health and safety requirements. More specifically, as detailed on the enclosed the Statement of Deficiencies (Form CMS2567), the contents of which are incorporated by reference herein, the survey completed on December 12, 2011, documented deficiencies that, on balance, reasonably support a conclusion…of continued noncompliance with Federal health and safety requirements”.

As a result of continued non-compliance with Medicare Conditions, a warning of de-certification is re-instituted.

Feb 2012  -

            Medicare lifts its decertification warning, as a result of a revised Plan of  Correction, which perhaps includes engagement of an outside clinical  compliance team. It is unknown whether a formal Medicare Compliance Plan exists, or if this represents the advent of such.

Aug 2012 –

            Pacurar implements a patient care staff retraining program, presumably in response to the findings reported by the outside clinical review team she has engaged.

Nov 8, 2012 -

            A moratorium on patient admissions is imposed for a weekend

Nov 12, 13, 2012  -

            In apparently the first press report(s) (SD Union Times) of the organization’s distress, several almost contradictory claims are attributed to President and Chief Executive Officer Pacurar.

o   Although post payment audit results are still unknown, Pacurar said she believes there will be enough financial pain to require layoffs of up to 200 of the hospice’s 870 employees. “The organization, after the first of the year, will look different than it does today,” Pacurar said. “It will be smaller. It will focus solely on the great care of hospice patients.”

o   Pacurar said she believes the hospice is vulnerable to millions in rebates to Medicare because the program has not been strict enough in making sure that its patients are truly suffering from an illness likely to cause death within six months. She said doctors and care givers operated for decades on an “open access” policy that kept patients on hospice care for longer than six months, sometimes without being able to demonstrate that their condition was worsening.

o   The executive said she also dismissed the hospice’s previous chief medical officer (also the Chief Financial Officer…reported elsewhere) and instituted a new compliance department that will regularly audit patient charts before requesting payment from Medicare.

o   It remains to be seen, she said, how much of that amount the federal government will want back. At first, officials said they worried that the number could be as high as 60 percent. However, a recent conversation with a Medicare official gave them hope to believe any rebate will not be so high that it will cripple the operation.“I’m quite excited about moving forward. I have recently added new leadership to help me execute the plan that we’ve developed to take us through this difficult time,” she said

o   Within weeks of that report, Medicare notifies the organization they will be subject to 100% pre-payment claims review, but that decision is almost immediately revised to 100% post payment claims review is instituted; serious payment interruption is averted

Dec, 2012 –

      In a December meeting of the Board of Directors, the month-old  Hospice Chief Operating Officer, who as subsequently revealed in a Bankruptcy Court deposition has no operational health care experience, much less hospice, presents an "analysis" to the Board of Directors and the CEO, ostensibly a strategic plan that features  two very grim options: (a.) continue to operate as best as possible,  under intensified regulatory scrutiny and possible financial damage as may potentially result from the Medicare audits, repair the organization and  maintain the 35 year-old mission or (b.) accept the second option which the gentleman admits he favors: Shut it down…

Feb 4, 2013 –

San Diego Hospice and Palliative Care Corporation files Chapter 11.  Subsequent reports reveal the Board of Directors decision made in  December to close the organization. Reports also cite some type of  affiliation arrangement with Scripps Memorial Hospital that provides (a.) SDHIPC a $5M operating loan, (b.) an offer to purchase SDHIPC-owned   real estate for $10.7M subject to bankruptcy court approval (c.) absorption of remaining employees as well as (d.) patients (subject to Scripps      qualification of eligibility) into a small (2012 unduplicated census: 86 patients), for-profit, licensed and certified hospice in Poway, which Scripps has acquired in the preceding days and weeks.

Mar 12, 2013 –

Deposition of San Diego Hospice & Institute of Palliative Care Chief Operations Officer:

 read here:


This is a troublesome story with substantial ramifications for free-standing community-based not-for-profit hospice and palliative care organizations across the country. More to follow.