How Often Should Patients with Advanced Illness Be Visited By a Physician?

We believe the role of the physician within hospices has been undervalued, and we would like to see the physician's participation increase in the care of long-stay patients.  That’s one of the messages to take away from the CMS regulation mandating physician (or nurse practitioner) face-to-face encounters to certify a patient’s continued hospice eligibility. The Medicare program reimburses a hospice nearly $30,000 over a six-month period to provide for the total healthcare needs of a patient with advanced illness– a single physician visit to that patient’s residence over that period isn’t too much to require, is it?

To me, it seems likely that such patients would benefit from a care planning visit by a physician. After all, the distinguishing feature of hospice care from most other care covered by Medicare is its collaborative nature, and the primacy of the interdisciplinary team. Such care, of course, lies at the core of palliative medicine.

Rather than treating this regulation as a compliance issue, hospice executives, and physicians, would do well to incorporate physician recertification visits into their clinical practice patterns. One can be confident that patients, and their families, will appreciate the value of these visits.

Recently, a family member passed away after a broken hip confined her to a skilled nursing facility.  A hospice program served her during her final three months. During that time, she was not seen by a hospice and palliative medicine physician. And while her (and the family's) hospice experience was positive, the interdisciplinary team concept seemed incomplete without a single bedside appearance from the physician.

HPM Physician Performance Management

At a recent regional assembly of hospice executives and Hospice and Palliative Medicine (HPM) physicans who had gathered to strategize about the advantages (and disadvantages) of building a provider network for late-life care, I was asked what tools are available to measure performance of HPM physicians (and nurse practitioners).  I suggested turning to the Joint Commission's standards on OPPE (which I have written about previously, read here) for a closer look into how hospitals are expected to evaluate  their medical staff practitioners. How might these standards be applied for HPM physicians in the hospcie setting?  Here's one approach to applying physician performance core competencies to HPM practitioners we've found successful:  
    
Patient Care. Providing patient care that is compassionate, appropriate and effective for managing
late-life care.

Medical/Clinical Knowledge. Degree of knowledge of established and evolving practices and principles of HPM, as well as the application of that knowledge to patient care and the education of others.

Practice-based Learning and Improvement. Use of scientific evidence and methods to investigate, evaluate and improve late-life care practices.

Interpersonal and Communication Skills. Establish and maintain professional relationships with patients, families and other members of health care teams.

Professionalism. Commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity, and a responsible attitude toward  patients, the profession and society.

Systems-based Practice. Understanding of the contexts and systems in which palliative care is provided and the ability to apply this knowledge to improve late-life care.

Of course, specific metrics need to be developed to evaluate performance in each of these domains.  The metrics  will vary from organization to organization and are  less important than the process of sitting down to develop the metrics. Yet,  doing so will take executives and physicians a long way toward satisying one of the building blocks of a high-performing HPM medical staff -  to  foster an unswerving commitment to performance improvement to minimize unwarranted practice variation, reduce regulatory risk, and win the confidence of referring sources.