Palliative Medicine - Undercapitalized and Overcommitted

The practice of palliative care, by physicians and advanced practice nurses, has gradually moved into the mainstream of American health care. While there is little debate over the need to improve late-life care, especially within acute and long-term care institutions, there continues considerable discussion over how to best improve it. Unlike most other medical specialties, palliative care is not reliant upon the effective formation of physical capital (diagnostic and therapeutic equipment using advanced technology) for its practice –to the contrary, it is totally reliant upon the effective formation of intellectual capital. Its effective formation is integral to the success of palliative medicine practices.
You’re thinking that palliative care is the lengthened shadow of a practitioner’s knowledge of clinical best practices. And, you’d be on the right track, for the provision of palliative care is based upon one component of intellectual capital, the know-how, skills, and competencies of the practitioners. Whether a practice or program has sufficient number of practitioners to render this knowledge-based care, first-hand, throughout the community, is a critical decision whose studied deliberation can tip the scales in a program’s outcome.
Two other components make up a program’s intellectual capital: one, structural capital (or infrastructure) - those workflow processes (automated or manual), revenue cycle practices, databases, and routines that enable effective day-to-day operations. The other is customer capital - or goodwill to many - the program’s relationship with its referring, and non-referring medical community, payers, partners, and, of course, its patients. The effective formation of these three components leads to the desired result – development and sustainability of the practice, and its affiliated programs.
So, what’s my point about being undercapitalized, you’re likely wondering? Most programs, and by extension the practices that support them, are subsidized by hospitals, hospices, or grants and philanthropy. This support is often renewed annually, thus demanding of the program’s managers a yearly impact statement of the program’s results. Long-term sustainability depends upon revenue generation, a business process oft shortchanged, at best, or neglected, at worst. This structural capital is often borrowed from the parent organization, whose resources, no matter how well intentioned, rarely offer the sharp focus, attention, and insider know-how so necessary to effective revenue capture.
OK, there may be a shortage of intellectual capital, but overcommitted? Palliative care specialists, were they to be queried, would remark that they don’t have sufficient time to develop the program. Programs report either of two situations – that palliative care has been widely adopted as the standard for late-life care in the community, and that there aren’t sufficient qualified staff to respond to referrals, or that palliative care has not sufficiently diffused throughout the community and a stronger referral base needs to be built. In either instance, what's lacking is a critical mass. Hospices provide part ofthe answer. So do hospital-based palliative services. Only Accountable Palliative Care Organizations (APCOs), through their effective formation of intellectual capital, have the capability of providing the entire answer.

Engage with Grace - Communicating End-of-Life Wishes

Some conversations are easier than others

Last Thanksgiving weekend, many of us bloggers participated in the first documented “blog rally” to promote Engage With Grace – a movement aimed at having all of us understand and communicate our end-of-life wishes.
It was a great success, with over 100 bloggers in the healthcare space and beyond participating and spreading the word. Plus, it was timed to coincide with a weekend when most of us are with the very people with whom we should be having these tough conversations – our closest friends and family.
Our original mission – to get more and more people talking about their end of life wishes – hasn’t changed. But it’s been quite a year – so we thought this holiday, we’d try something different.
A bit of levity.
At the heart of Engage With Grace are five questions designed to get the conversation started. We’ve included them at the end of this post. They’re not easy questions, but they are important.
To help ease us into these tough questions, and in the spirit of the season, we thought we’d start with five parallel questions that ARE pretty easy to answer:







Silly? Maybe. But it underscores how having a template like this – just five questions in plain, simple language – can deflate some of the complexity, formality and even misnomers that have sometimes surrounded the end-of-life discussion.

So with that, we’ve included the five questions from Engage With Grace below. Think about them, document them, share them.

Over the past year there’s been a lot of discussion around end of life. And we’ve been fortunate to hear a lot of the more uplifting stories, as folks have used these five questions to initiate the conversation.

One man shared how surprised he was to learn that his wife’s preferences were not what he expected. Befitting this holiday, The One Slide now stands sentry on their fridge.

Wishing you and yours a holiday that’s fulfilling in all the right ways.

(To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team. )

Why Intellectual Capital Matters to Growth of Palliative Care Programs

Our experience and research within palliative care have shown that "program champions" have been successful not so much because of what they bring to the role, but what the organizational program sponsor brings to the program champion. Certainly, a multi-talented physician champion increases the chances of success, but we've found it is the tools (intellectual capital) that she/he has to work with that are the primary determinants of success. The physician starting a practice (which is essentially what the program champion will be doing) needs to have strong clinical skills and knowledge, to be sure, but will need also to create goodwill (to build solid referral patterns), establish business processes, workflow, and databases, and generate revenue to produce a sustainable program. Organizational sponsors typically don't possess this intellectual capital specific to palliative care, and so, champions often find themselves stretched to produce results with little "infrastructure". As a result, the program champion finds her/himself spending time toward "marshalling" resources, at the expense of "deploying" those resources to grow the program.

Palliative Medicine Physician Compensation

In delivering current information to help clients and candidates and make informed recruitment and career decisions, DAI Palliative Care Group compiles and updates compensation information for physicians with a full-time practice in hospice and palliative medicine (HPM). We know how important the latest trends in physician salaries and compensation are to the negotiation process. These statistically evaluated results pinpoint mean (average) and median HPM physician compensation by:

§ Region
§ Title
§ Size of organization
§ Gender

Earlier this year, DAI Palliative Care Group made available for purchase, for the first time, the 2008 report for HPM physician compensation. We are currently updating this compensation information, and will soon have available the 2009 Report. As you might expect, compensation rose nearly 10%. And as you might also expect, compensation for full-time HPM physicians continues to lag behind other primary care sub-specialties - that of family practitioners by 9% , and internists and hospitalists by nearly 15%.
While overall numbers do not yet suggest a groundswell movement, more employers/practices are shifting away from straight salary to a combination of income guarantee and productivity incentives.

Drop me an email at tcousounis@digital-action.com , mention that you saw a reference to the Report on this blog, and I'll arrange to have the 2009 Report sent to you electronically (in PDF format) at a professional courtesy rate. It could be worth thousands to you.

Palliative Medicine Physician Practice Profile-interview with HPM Physician Amy Mohler,MD

Grand Junction, CO, was recently lauded in the news media and at a town-hall meeting with President Obama as "a health community that works" -- "-for controlling health care costs while maintaining high quality. Data from the Dartmouth Atlas and from the DAI Palliative Care Group show it to be an exemplary palliative care community as well, based on metrics such as lower rates of in-hospital deaths, fewer hospital readmissions, less reliance on ICU care and higher hospice enrollments. (For more information on DAI's palliative care community metrics, see www.DAIpalliativecaregroup.com.)

"We can't take all of the credit," quips Dr. Amy Mohler, a board-certified hospice and palliative physician and the Chief Medical Officer of Hospice and Palliative Care of Western Colorado (HPCWC). The local medical culture emphasizes the role of primary care physicians. Grand Junction's non-profit hospitals and health plan came together 16 years ago to establish HPCWC as hospice provider for the entire community. "Those entities have been in Grand Junction for decades, and our medical culture has grown from the ground up. But for the past 16 years, HPCWC has been an integral part of that system," Dr. Mohler says. "I see great collaborative relationships here, and our local physicians are very open to our palliative expertise and to getting calls from us whenever we see opportunities to improve our patients' symptoms and quality of life." The hospice's census has grown to 250 in a metropolitan area of less than 140,000 people. HPCWC also offers in-hospital and community-based palliative care consultations, community bereavement services, grief programs for children and teens, and a cadre of 1,200 volunteers. It also operates three satellite hospice teams an hour or more from Grand Junction. "Grand Junction is like the poster child for primary care, and this is fertile ground to be passionate about your work," says HPCWC CEO Christy Whitney. "Even before our hospice existed, there was a very active non-profit HMO, Rocky Mountain Health Plans, that closely monitored hospital days. But I believe we have helped considerably to lower hospital days at the end of life, which means lower end-of-life costs. Having excellent hospice physicians who are available for teaching other physicians has also helped us make inroads."

Scheduling, Compensation and Call

Dr. Mohler and two physician colleagues work full-time for HPCWC, dividing up medical responsibilities for 12 hospice interdisciplinary teams based in home settings, nursing homes and assisted living facilities. Four days a week, Dr. Mohler sees patients at the hospice's freestanding 13-bed inpatient unit, which opened last October. The other doctors put in four-day work weeks heavily tilted toward direct patient visits, which are scheduled and geographically bunched by an administrative assistant. They generally make four or five home care or six to eight facility-based visits per day, and the local geography does not impose long driving times. "We try to get all of our new hospice patients seen early in their admission, especially since we see 30 percent of them for seven days or less," Dr. Mohler says. Each physician spends about an hour a week on interdisciplinary team meetings, with each team coming together every other week for a tightly structured reporting format to get through 20 to 25 patients within 30 minutes. "We used to be quite fantastic about allowing the IDT to run for hours, which wasn't helpful to anybody," Dr. Mohler says. Regular contacts between IDT meetings include "mini-team" updates and frequent phone calls. This year HPCWC implemented a productivity model for compensating its staff physicians, based on their billable visits, with a base salary to cover essential administrative activities. "I think everyone is happier with it, in terms of their workload. If they want to make more money, they know they can work harder and make more visits. If they like their balance of quality of life versus workload, that's okay too. The expectations are clearer and there's a feeling of shared responsibility," Dr. Mohler says. Between them, the three doctors also divide up evening on-call coverage, "physician-of-the-day" responsibilities, including first response for palliative care consultations, and three-day weekend call, including daily patient visits at the inpatient care center. The three-day weekend shift is designed to give the doctor on call more time to acclimatize to the needs of those patients. That may seem like a lot of call responsibilities, especially with the spectacular scenery of Western Colorado so close at hand. But it really isn't as bad as it sounds, Dr. Mohler says. "We find the schedule is still reasonable, because of the emphasis on primary care physicians in this community, their investment in what happens to their patients, and our commitment to supporting that relationship. That translates, when we are on call, into serving more as specialists consulting on their patients, so that our responsibilities aren't such a huge deal," she explains. "Our staff knows that when something is going on with a patient, their first line of help is the primary care physician. They still may call me to spend a few minutes running through the scenario and what might be most helpful for the patient, before they call the physician. I tell the nurses they need to know what they want to ask for from the doctor in a given clinical situation before they place that call." Still, the hospice is finding that three physicians are not enough to cover everything that needs to be done, especially since a nurse practitioner who made most of the in-hospital palliative care consultation visits moved away earlier this year. "When you are the doc of the day, you're in the hot seat. You may get the consultation call that comes in at ten minutes before five. But we're not doing a huge volume of inpatient palliative care consultations right now. We also have a community-based nurse and social worker palliative care team that uses more of a case management model, with a current census of 58," she says.HPCWC hospice teams in the three satellite offices draw upon local community physicians in part-time or volunteer roles to staff their hospice teams. The three full-time hospice doctors in Grand Junction are HPM-certified, but the four part-time satellite physicians, who have full-time clinic practices in internal medicine or family practice, are not. The satellite team physicians don't make many home visits. "If there are complex patients who need to be seen, we try to make special arrangements for seeing them out of this office," Dr. Mohler says. The agency also has a medical suite available at its inpatient unit to see patients who may be in central Grand Junction for other medical services. Dr. Mohler would like to have more time for visiting the satellite sites and working hands-on with their physicians and teams, rather than doing that by phone and email. Current plans are to recruit a fourth full-time physician for HPCWC while perhaps involving other Grand Junction physicians in on-call coverage and encouraging the satellite office physicians to enhance their palliative care skills through occasional shifts at the inpatient unit.

A Representative of Hospice

Although Dr. Mohler's job is largely clinical, covering the inpatient unit Monday through Thursday, Friday is spent in the hospice office on administrative functions. These include supervising the other physicians, participating in quality improvement activities and on the hospice's senior leadership team, teaching in a local family practice residency program, staff teaching, educating the local physician community and the public about hospice care, and "quite a lot of social networking as a representative of hospice."
"We have made a big investment in physician services. At our best we cover only 50 percent of medical costs from billing revenues," Whitney says. "But we decided to make that commitment, and having Amy, with her geriatric background, has been fabulous for our patients. My feeling is that hospice and palliative medicine is a specialty. Having our physicians available by phone supports our nurses, who sometimes have a hard time reaching the attending physician when they're out in the field. It brought a higher standard of care to our patients, and it gives us the opportunity to truly practice evidence-based medicine."
Dr. Mohler has been with HPCWC for seven years and its Chief Medical Officer, a position created to oversee the medical care provided by the other hospice physicians, for the past 18 months. An Arizona native, she trained as an internist and did a geriatrics fellowship at Good Samaritan Hospital in Phoenix. "I always knew that I would do geriatrics and, specifically, long-term care. But I became interested in end-of-life care during my residency," she says. "I spent so much time in the hospital and ICU and attended so many deaths there that I just felt there had to be a better way."