Will Health Reform be Kind to Palliative Care?

Were I a betting person, I'd wager a princely sum on our getting within the next year a major reform of the health care system. Why am I so confident? Because the auto makers financial crisis will highlight the nation's health care cost issue. The "car czar" will make sure of it. And while the implications and ramificiations of "reform" will undoubtedly be wide-ranging, I've given to wonder what reform will mean for palliative care in general, and palliative medicine practices specifically. Mounting signs suggest that reform will be, indirectly, unkind to palliative care. In upcoming posts, I'll offer my take this subject. In the meantime, I invite yours.

Exceptional Palliative Medicine Practice Opportunity

Earlier this year, I was asked by a journalist who covers the hospice industry to comment on the future practice opportunities awaiting physicians interested in practicing palliative medicine.
I commented in that piece that the traditional role of hospice medical director was in the midst of evolution, to which I added that was a positive development since this traditional role would not suffice (no matter how well paying) in attracting talented physicians to the field. Some interpreted my comments as an assault on the fine work done by hospices in this country. On the contrary, I see physicians serving as the keystone for the development of Advanced Palliative Care Organizations - below, I describe a current practice opportunity with which I'm working that typifies the sort of position that will become prevalent in communities across the US.
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You'll showcase both your clinical expertise and business savvy as you implement clinical and business development strategies for our client’s palliative care service. The service was initiated in 2005, backed by several years of assessment and development, and promises to redefine how end-of-life care is provided in the flagship hospital of one of the most highly regarded health systems on the East Coast. This service has generated significant interest among key stakeholders, who are eager to integrate these palliative care protocols into their practices.

This hospital-based palliative care service accounts for one of the most important strategic initiatives over the next 24 months. While some strategy is in place and activities have been underway for some time (currently about 70 consults/month), you'll put your personal stamp on these programs as you expand development efforts and provide palliative services to patients in acute and long-term care settings.

The success of this program will provide impetus for more palliative services within the health system.

What You'll Bring to the Table

MD or DO, Board certification in primary specialty and palliative medicine
Experience in delivering hospital-based palliative care services, including a successful track record of advancing palliative care programs through clinical development.
Deep knowledge of clinical practice guidelines for quality palliative care and understanding of quality improvement methodology
Ability to effectively lead, manage, and participate on multi-disciplinary teams.
Strong interpersonal, public speaking, written communication skills.

Your Unique Opportunity

This position offers many unique benefits:

Stability – the palliative care service has received senior management (of both the sponsoring hospice and health system) authorization, and has been well received by clinicians throughout its introductory period

High visibility -- your visibility to hospital executive team is a "given;"

Exceptional work environment -- each employee is expected to contribute toward shared goals, to sustain a working environment that is team-oriented, professional, challenging and friendly.

Career development -- your purview will include both development and implementation, and an opportunity to develop a thriving practice in palliative medicine throughout the health system

High impact -- your success in building out the palliative service within the will enhance our client’s reputation as a leading provider of care for those with life-limiting illnesses

About the Organization

One of the largest not-for-profit hospice and palliative care enterprises (more than $60 million in patient service revenues) serving multiple counties in Virginia and the DC metropolitan area. This organization is highly regarded in its communities for its end-of-life care, and receives considerable philanthropic support. It serves daily more than 600 patients through its certified hospice, inpatient hospice unit, and its facility-based palliative care service.

Compensation

Total earnings potential will top $150,000
In addition to a salary guarantee, this position offers a comprehensive array of benefit programs designed to meet the needs of you and your family, including medical, dental, vision, STD and LTD insurance, 403(b) investment options, paid vacations and holidays, and employer-paid professional malpractice insurance,

More About Your Role

Reporting to the Senior Medical Director, in addition to direct patient care, your activities will include:

Identifying tension points to aid in marketing palliative care services to clinicians
Developing strategies to build sustaining relationships with community partners
Establishing palliative care as a recognized service within the affiliated hospitals, nursing homes, and community clinics
Serving as physician member in education and training of clinical staff, and oversight of palliative program staff
Planning timetables and budgets for program development.
Traveling to clinical affiliates throughout the service area to deliver and oversee palliative care services

Keys to Success

To excel in this role, you will:

Apply your clinical knowledge of palliative consultations and experience with program development to drive the palliative care service forward quickly
Leverage your understanding of the nuances of success in the development of palliative care programs
Be recognized throughout the hospital as the leader (subject matter expert) of palliative care

Hospital Palliative Performance Profiles, part 2

I'm often asked to describe the key elements behind the success of Advanced Palliative Care Organizations, and to cite specific examples across the country. Similarly, I'm asked how we determine the performance of communities and hospitals around palliative care. Simply put, we use the Dartmouth Medical Atlas, and seven outcome measures in the study considered by those whose palliative care knowledge I hold in high regard to be reliable indicators of the prevailing end-of-life care practices of hospitals and communities. These measures relate to place of death, referrals to hospice, use of intensive and acute hospital care during the final six months of life, and the coordination of physician care during those final months.
We then examine the hospital's performance in these palliative outcome measures, against local, state, and national performance data. Hospitals are assigned points based upon their performance against these standards, which when aggregated reflect their Palliative Performance Score. Hospitals are then graded, as follows, based upon their score.

100 - plus A best practice, exemplar
75-99 B solid performance, commendable, aspiring leader
50-74 C common performance, middle-of-the-road
25-49 D below-average performance, needs considerable improvement
less than 25 E complete overhaul necessary of current practices


Curious about your hospital(s) performance in palliative care? Drop me a line at tcousounis@digital-action.com.

Hospital Palliative Performance Profiles

Since 1996, the Dartmouth Atlas of Health Care has tracked patterns of health care delivery, practice and quality across the country. Its massive pool of national, regional, local and provider-level health care utilization and cost data, derived from the Medicare database, has documented striking geographical variations in the delivery of health care services. But it has also changed our understanding of the efficiency and effectiveness of health care delivery and demonstrated that more medical care does not necessarily mean better care—that the wide disparities in health care spending and utilization do not track with measurable improvements in health care quality. In fact, higher utilization at the end of life may represent both harm to patients and billions of dollars in wasteful and unnecessary health care spending.

The Dartmouth Atlas Project, founded by Dr. John E. Wennberg, is based in the Dartmouth Institute for Health Policy and Clinical Practice at Dartmouth University. Its databases are used by health care policy-makers, analysts, health care executives, researchers, and, increasingly, palliative care advocates seeking to plan or justify the need for palliative care services to help their hospitals better manage these high-need, high-cost, high-utilization patients.
“Concern about overly aggressive care for patients at the end of life has sparked increased interest both in palliative care and in aligning the kinds of services provided to dying patients with their well-informed preferences,” the report states. “Patient wishes may have less influence on intensity of care than the practice patterns of the hospital where the care is given.”

Taken together, these figures start to sketch a picture of how much potentially futile or ineffective care a hospital or a region provides to patients during their final months of life or during the hospitalization in which death occurs—as well as creating an opportunity to compare performance on these variables among peers.

Our analyses show there is great variation in end-of-life care across regions and states. Digging deeper, our research group has identified that those hospitals with high performance scores (100 or above) have adopted advanced palliative care organizational (APCO) principles in which there are what we refer to as “learning communities”. This learning community is essentially a group of palliative care stakeholders who "join" together and are driven by a desire to share problems, knowledge, experiences, insights, templates, tools, and best practices around palliative care.

I'm interested to hear from those involved in learning communities sponsored by APCOs.

Hospice Medical Staff Development Plans

Trained as a hospital administrator, and having worked in hospital executive positions, I've seen the power of careful and timely hospital medical staff planning in furthering a hospital's commitment to its community's health. Effective medical staff development offers other benefits to the hospital, not the least of which, I've found, is that a link will be created between the physician recruitment campaign and the hospital's strategic plan and its growth objectives.

So, I've wondered frequently since my career headed into the palliative care field, would medical staff development plans (MSDPs)for hospices produce similar benefits? My experience suggests that they would. As hospices move beyond their traditional role of serving terminally ill patients who have elected to use the hospice benefit, and toward a leadership role in shaping end-of-life care throughout their communities, the role of the hospice’s physician staff is being redefined. Hospices are evolving into advanced palliative care organizations in which care spans organizational and professional boundaries, while integrating physician services into a traditional nurse-centric organization, and simultaneously adopting a collaborative model. Such a convergence will, unsurprisingly, strain an organization’s resources and its roles.

At their best, MSDPs are an objective quantification of community need on a palliative care basis. The challenge, we've learned, is identifying a standard for staffing of programs. In developing a plan, we consider the following:
-Variability in clinical commitment of current staff
-Presence and clinical role of providers such as NPs and PAs
-Presence of academic practices that may include teaching and research
-Productivity data to analyze MD capacity to absorb additional volumes

So what can a Hospice MSDP offer to the executive leadership of a hospice?
An assessment of community practice around end-of-life care to identify improvement opportunity, and to translate community needs into physician staffing requirements and associated financial commitments. An assessment of the hospice's current capacity, the identification of competencies that are likely to accelerate growth, and the creation of practice opportunities that attract talent and fill competency gaps. Armed with this information, hospice executives are solidly positioned to make a difference in the palliative care practices within their community.

I'm confident that other hospice execs have had related experiences. I'm curious to learn your feedback.

Role Definition and Advanced Palliative Care Organizations

I'm asked from time to time why I consider palliative care to be two parts accomplishment for three parts potential. I offer many reasons in reply, but none (in my opinion) have a greater impact on the success of palliative medicine programs than role confusion.

The highly collaborative nature of palliative care services (and by extension, advanced palliative care organizations) requires sharp role definition. Ideally, what a person thinks his or her job is, what others expect of that job, and how the job is actually performed are all the same. Role confusion, however, is a common byproduct of the service/program launch process. Role perception “drift” is natural, especially as insufficient resources are strained to meet growing demand for the service.

So that fledgling programs can better identify and eliminate such drift, program sponsors should, up-front, clearly delineate roles and expected results. Most program developers do this through job descriptions, yet, for all of the benefits that accrue from traditional job descriptions, role definition is rarely one of them. I've successfully used a management tool known as Responsibility Charting to systematically identify decisions and activities that must be accomplished and to pinpoint the functions (positions) that will take on roles relevant to those results. Among the benefits that may flow from this process:
-increased productivity through well-defined accountability
-increased capacity through elimination of overlaps and redundancies
-streamlined organizational structure achieved by collapsing unneeded layers and placing accountability closest to the decision
-improved communication and collaboration.
In other words, a strong performance management program for the palliative care service that will guide leadership and palliative care specialists.

Advanced Palliative Care Organizations -An Organizational Model to Distribute Palliative Care

Hospices are especially adept at managing patients close to the end-of-life. My study suggests there are two reasons - because the number of such patients that hospices serve is so large (more than 50% for many hospices) AND because the most challenging patients (clinically and financially) are those with lengths of stay of 10 days or less. Several research studies have found that the most costly periods of care, under the hospice benefit, are the FIRST five days of enrollment on the hospice benefit and the LAST five days of life. So it's natural to expect that hospices will become proficient in managing "short-stay" patients.Currently, palliative care in this nation is organized, and thus delivered, around the hospice benefit. No question, greater accessibility to better end-of-life care has resulted since Medicare introduced the hospice benefit. I believe most of us would agree,however, that palliative care applies to many more patient populations than those fast approaching end-of-life. How can we best assure that chronically ill populations benefit from palliative care? By reorganizing, around Advanced Palliative Care Organizations, how health care is provided to those with life-limiting diseases.

Defining the Role of Medical Leadership in Successful Palliative Programs

The keys to success, we've found through study and experience, are to align expectations and to create an organizational structure that enables easy scaling to accomodate growth.Job specifications based upon program metrics generally produce the best results , that is to say, the role of program director is best determined by identifying and incorporating into the position profile the program expectations from at least three and not more than five "stakeholders', including the CEO. This can best be done done by an outside consultant who will not inject "bias" into the assessment.

Removing Barriers to Success

I'm often asked what keeps programs from reaching their potential? Several factors, but one stands out.
A program can be successfully STARTED with less than 1.0 FTE - the challenge becomes in sustaining the program with such limited staffing. The shortage of palliative care specialists makes timely scaling of the program one of, if not the greatest, management challenges. Those that have been able to SUSTAIN the program with limited staffing have done so because they've effectively brought infrastructure (intellectual capital) to the program at the right time and in the right amount. Yet , as one might surmise, doing so demands management agility and acumen and, most precious of all, time. These are resources in short supply at most fledgling programs.
In future posts, we'll examine several other barriers to program growth, and how successful programs have surmounted those obstacles. Most of all, I'm curious to learn experiences of readers of this blog.

Two Parts Accomplishment, Three Parts Potential

Two parts accomplishment, three parts potential. That, to me, describes the current state of palliative medicine.
How can that be, you ask? After all, palliative medicine is now a recognized subspecialty. And the clinical domains of good palliative care are being adopted widely.
So why is the promise of palliative medicine yet to be realized, and what will it take to translate potential into accomplishment? While palliative medicine practices are delivering exceptional care to those with life-limiting illnesses, many demonstrate unfilled potential. Why? Because they’re undercapitalized; not financially, but intellectually. The bulk of each practice’s intellectual capital has been invested in the clinical knowledge residing in the physician’s head. And that’s the way it should be. But what about other intellectual capital—efficient workflow processes, coding expertise, knowledge of palliative medicine reimbursement nuances, practice analysis intelligence, software, and marketing know-how—so essential to the achievement of a high-performing practice? Most palliative medicine programs labor without this intellectual capital, and find themselves a year or two later scrambling to justify continued viability either of the practice itself or the palliative program associated with it.
Sponsors of palliative care programs, usually hospitals and hospices and most surely all well-intentioned, discover that sustaining (and growing) a program requires a different set of skills and expertise than developing the program. They also underestimate the importance of organizational structure in the success of the program. My aim is of this forum is that we'll examine the key elements of APCOs, the barriers to success and how they might best be removed, and why the shortage of palliative care specialists threatens to stifle the progress of end-of-life care.