A Competency-Based Model for Evaluating Performance of Palliative Care Practitioners

At a recent regional (virtual) assembly of hospice executives and Hospice and Palliative Medicine (HPM) physicians 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 hospice 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 collaboratively develop the metrics. Yet,  doing so will take executives and physicians a long way toward satisfying one of the building blocks of a high-performing HPM practitioner staff -  to  foster an unswerving commitment to performance improvement to minimize unwarranted practice variation, reduce regulatory risk, and win the confidence of referring sources.

More to follow on this blog regarding the use of competency-based models to elevate the performance of palliative care practitioners.

How Effective are Hospices in Spreading the Science of Palliative Care?

 Medicare-certified hospices are the principal organizational model delivering palliative care to those with life-limiting illnesses.  A close look at NHPCO's Annual Facts and Figures (2020 version recently published) reveals much about the hospice industry and the spread of the science of palliative care.

The industry continues to be subscale, hindering the development of clinical proficiency. For example, more than half of US hospices admit fewer than 2 patients per week (same as five years earlier). See here for previous blog post arguing the case that proficiency in health care is related to volume. Furthermore, more than 25% of hospices have been newly certified in the last few years, another important consideration in the development of proficiency. One might argue that the number of people utilizing the hospice benefit to receive palliative care has been growing (in 2018, more than 50% of Medicare decedents received palliative care through a certified hospice), thus justifying a greater number of hospices in the country, but the % growth in the number of hospices in the US exceeds the growth in the number of Americans utilizing the Medicare hospice benefit.  I suggest  that the large variations in late-life care will continue until the hospice industry gains in scale. (read here for more on clinical variations in late-life care).

On a more promising note from the 2020 NHPCO report, the  percentage of short-stay patients (those receiving palliative care through the hospice benefit for seven days or less) dropped to 27.9%, from 35% five years ago.  So an issue (timely use of hospice benefit) some thought intractable 10 years ago (read here) may be gradually improving.

As always, your insights and feedback are invited.

Exemplary Performance in Late-Life Care - How Much More Do We Know Than 10 Years Ago?

 

The post below (Improving Late-Life Care...) appeared in 2010, pondering what outcomes constituted exemplary performance within a community as it pertained to late-life care practices.  Over the intervening decade, the analysts at DAI Palliative Care Group have been gathering a few more insights. 

To name a few:

• Palliative care specialists within these communities recognize life’s completion can present serious financial challenges. Their competencies "extend" into resourceful coordination of reimbursement so that access to care is not limited by unaffordable services.
• Palliative care leadership in these communities believe in "positive dissatisfaction, that is, they always strive to do better.  They are insistent upon measuring quality, closely monitoring outcomes, implementing improvements, and tracking patient and family satisfaction. 
• These community exemplars commit themselves to the three As of access: affordability, availability, and awareness.  

We'll explore these communities, and practices, in more detail in future posts. In the meantime, your thoughts and reactions are appreciated.

Improving Late-Life Care - Do We Know Exemplary Performance?

We're starting to learn more about late-life care, thanks in large measure to the Dartmouth Atlas Project.

For example, in a recent report  Trends and Variation in End-of-Life Care for Medicare Beneficiaries
with Severe Chronic Illness (read here),  we learned more about the final 30 days of life of a patient with cancer. More than half (54.7%) were hospitalized during that period. 5.6% received life-sustaining procedures. Half of the final month was spent in hospice (11 days) and an acute-care hospital bed (4 days). Interesting, but without context. Likely, the past 10 years has seen considerable improvement in these measures. How much more improvement should we expect? Can hospitalizations be cut in half? If so, what might be the most effective methods? A transitional care document , like POLST? A provider reimbursement structure where collaboration, rather than procedures, is more highly valued? A community palliative care officer who's accountable  for late-life care across settings within a specific community or region? Any of these, or all of them?

And how much better can the health care system do to encourage earlier referral to palliative services, so that greater than 11 days out of the final 30 can be spent under hospice care?  As always, your ideas and opinions are invited.

The Power of Palliative Care - Has Potential Turned Into Accomplishment?

Using publicly available data, such as the Dartmouth Atlas, annual NHPCO Facts and Figures reports, and MedPacDataBooks, the DAI Palliative Care Group  has been preparing late-life care performance profiles for our clients and selected audiences. See here, here, and here for previous blog posts on this subject.

These performance profiles have been measuring and tracking the performance of communities, hospitals, and states, using key indicators of palliative care,  since the early 2000s. By identifying exemplary performers, our reports have inspired individual and institutional providers, collaboratives, as well as entire communities, to aim higher, thus  strengthening the power of timely palliative care interventions  to improve late-life care in the United States.  Our analysts have recently produced another report  which tracks outcomes over time for  a set of key indicators.

Several highlights of the report:

-fewer Americans are dying in the hospital.  In 2007, 31.7% of  US deaths occurred in a hospital. The high-performance benchmark , that is, 10% of communities across the nation achieved this performance level, was 22.5% for that year.  In 2017, 20.1% of deaths occurred in a hospital. So, over the span of a decade, the nation's performance moved from average to high-performing.  How much more potential for improvement is there?  The cities of Sarasota, Fla. and Asheville, N.C., which were high-performers in 2007, are now at 14.2 and 14.1% respectively.

-Americans spend less time in a hospital during last six months of life.  An American who died in 2007 spent almost 13 days in a hospital during the last six months of life. In exemplar communities, that figure of days in hospital was almost 30% less (9 days).  Ten years later (2017), the national figure had dropped to 8.1.  Once again, a significant improvement.

-fewer Americans in 2017 were admitted to intensive care (14.7%) during their last six months of life than 10 years earlier (19.2%). Again, impressive improvement.

Undoubtedly, many factors contribute to these improvements. Surely, one factor has to be the greater accessibility to timely, high-quality palliative care.

I'm interested in your thoughts.

The Power of Palliative Care Interventions in Late-Life Care

A previous post on this blog  (read here)  asked  whether we're moving closer to identifying exemplary performance in late-life care.

A recent DAI Palliative Care Group analysis of data from the Dartmouth Medical Atlas suggests that palliative care professionals are indeed making a difference in late-life care, at least in some measure.

Our analysts looked at results  over a ten-year period from 2004  to 2014, using top 10% of performers as a proxy for exemplars.  For example, in 2004, 29.5% of all Medicare deaths occurred in a hospital. That same year, the top 10% performing communities saw fewer than 22.7% of deaths occurring in hospitals.  Ten years later, the national average stood at 20.3% (or put another way, average performers were doing 10% better than exemplars 10 years earlier).  Meanwhile,  exemplar communities were now  seeing less than 16.3% of deaths taking place in a hospital.

Almost as impressive is the reduction of inpatient days per decedent in last 6 months of life. In 2004, the average decedent spent 10.9 days in a hospital during last 6 months of life, while exemplary performance weighed in at 7.3 days or fewer.  In 2014, average performance was down to 7.9 days (while an improvement of nearly 30% it fell short of reaching exemplar performance of 10 years earlier), and exemplar performance now stood at 5.3 days.  Likely, many factors contribute to this improvement, but one cannot underestimate the power of palliative care interventions toward this improvement.

Any measure that did not see significant improvement?  Yes, % of decedents spending at least 7 days in ICU during last 6 months of life. Average in 2004 - 14.1%. In 2014 - 13.8%. Meanwhile, in late-life exemplar communities in 2014, only 5.3 % of decedents spend 7 days or more in an ICU during last 6 months.  A considerable opportunity for palliative care professionals to once again demonstrate the power of timely palliative interventions to match patient and family preferences with the care they receive.

Accountable Palliative Care Organizations - An Opportunity 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) www.polst.org 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.

Salary Compression Stalls Growth of Hospice and Palliative Medicine Specialty

Hospices and hospital-sponsored palliative care programs are experiencing increased demand for physician services in clinical and quasi-administrative capacities (read here for an analysis by the Center to Advance Palliative Care on the growth of palliative care programs). As these organizations build their medical staffs by employing additional HPM physicians, they're finding that creating and filling "leadership" opportunities are proving to be a formidable challenge. Why?

The features of a compensation program  that enable staff growth become liabilities when the principal objective of medical staff development turns to leadership building. Some compensation experts label it salary compression. Others refer to it as salary stagnation. Either way, it is the result of forces currently converging in the palliative medicine sector.

When there is a shortage of credentialed professionals, the imbalance between qualified people available to fill positions and the demand for physicians forces hospices, hospitals,  and other program sponsors to offer higher salaries to attract the limited number of qualified applicants. And when insufficient revenue sources limit funding for medical staff development, those limited funds are typically used to attract new staff members. While such a priority enables staff growth, compression at the "senior" medical director levels typically results. Salary differentials between the ranks have an increased potential for erosion. And so leadership opportunities look unattractive, and prospects (both inside and outside the organization) shun opportunities that in all other respects represent a professional advancement opportunity.

Some hospices, and a few hospital-based palliative programs, have implemented structural modifications to their HPM physician compensation program, with varying degrees of success. But success, nonetheless. It all begins with a reevaluation of the "value" placed upon HPM physician activities and responsibilities.

Choosing Where to Retire Based upon Experience Ratings About Late-Life Care

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.

Five Year Snapshot of Hospice Industry - What Does It Say About the Spread of Palliative Care?

Hospices and hospitals are the two principal organizational models delivering palliative care. The Center to Advance Palliative Care (CAPC) has consistently documented, through its regular studies, the growth of hospital-sponsored palliative care services over the most recent five years. During the same period, little has changed among certified hospices.

A close look at NHPCO’s Annual Facts and Figures Reports from 2009 and 2014 tells a lot (note:2014 report, which captures data from 2013, is most recent Report published by NHPCO).

From 2009 to 2014,

• ·        % of decedents enrolled on hospice benefit for 7 days or less remained steady at 35%
• ·         median length-of-stay fell slightly to 18.5 days from 21.3
• ·         % of hospices with fewer than 500 admissions per year rose slightly to 79% from 77%. 45% of hospices admit fewer than 3 patients per week
• ·         median Average Daily Census (ADC) served by hospices increased notably, to 79.5/day, up from 60/day
• ·         % of total hospice billed at General Inpatient (GIP) days  jumped to 4.8, up from 2.9.

So, short-stays persist, as do subscale hospices. I believe there is a correlation.  And I also believe that the subscale, and highly competitive, nature of the hospice organizational structure inhibits the spread of palliative care.

On the promising side, larger hospices are getting larger. I describe this development as promising because size does bring proficiency (read this previous post on my reasoning about minimum volume thresholds).

In a 2010 post on this blog (read here), a similar five-year snapshot was taken. Taken together, one could conclude that little has changed over the past 10 years in the hospice industry.

Your thoughts and comments are invited.

Palliative Care - Diffusing the Health Innovation

A graduate student in a Health Policy program asked me during a Q&A session at a national colloquium why I characterize end-of-life care in this country as three parts potential for two parts accomplishment. I've been asked similar questions before, but what gave me pause this time was the context of the query (the workshop was addressing the issue of access to hospice). The previous speaker had just presented a strong case statement on why access to hospice has been threatened by the "cap". And why the main reason for the decelerating growth of hospice was poor reimbursement.
I replied that the delivery system for late-life care is fragmented, and there is insufficient collaboration among providers within most communities. Thus, conditions are uninviting for the "spread of the science" (palliative medicine and nursing).


 The Center to Advance Palliative Care (CAPC) has effectively spread the science throughout the hospital sector, as it relates to hospital-based palliative care services. No small accomplishment, to be sure. But the other major palliative care providers (hospices) have been slow to scale, in part because hospices have taken competitive stances to protect their market share rather than the collaborative approach which studies have shown to be more conducive to the dissemination of best practices.  Communities known as providing high-value late-life care are characterized by several attributes - one of the most defining is a coalition (some might say network) of palliative care stakeholders (organizations and individuals) which come together to deliver care across settings and boundaries. The beginning of an Accountable Palliative Care Organization (APCO), some speculate.



The structure of the social system can facilitate or impede the diffusion of health care innovation, concluded Thoms Bodenheimmer, MD, in a September 2007 report for the California Health Care Foundation on how innovations in health care become the norm. Do the current social systems in our communities best position HPM leaders to 'spread the science"? As always, your comments are invited.

Use of Hospice Benefit has Slowed – What This Means for Palliative Care

A recent analysis of Medicare claims by Healthcare Market Resources found that enrollment onto the hospice benefit has plateaued (see blog post Hospice Utilization: Is Hospice Stuck in a Rut?). When one considers that the hospice benefit has been the principal source of reimbursement for palliative care, and that Medicare-certified hospices have been the principal delivery model for palliative care, these findings should raise concern among advocates of palliative care and those dedicated to improving its access.

What does the evidence suggest? States that historically have had among the highest utilization rates (such as Florida and Arizona) are now experiencing declines in utilization rates, suggesting that the utilization rate of those states may have reached the natural peak of hospice enrollment. Of course, low-utilization states have growth opportunities, as  states in the top quartile of hospice utilization rates use the hospice benefit 75% more often as states in the bottom quartile: 3.23% (on average) versus 1.85% (on average).  The key question to be asked: is growth in hospice benefit use in those lower quartile states sufficient to drive the spread of, and improve access to,  palliative care? I think not.

To be sure, efforts by organizations like Center to Advance Palliative Care (CAPC) have yielded impressive results, especially among hospitals and more recently through outpatient practices, in disseminating the science (and art) of palliative medicine. Yet, when the primary vehicle for reimbursing and delivering palliative care stalls, it may be time to look at newer vehicle models. Perhaps the time has arrived for Accountable PalliativeCare Organizations.

As always, your feedback and thoughts are invited. And more will follow on this subject.

Medical Staff Development Plan - Why It's Essential to a Hospice's Growth

Resourceful (and strategic) use of physicians in hospices and palliative care programs has proven to accelerate the success of creating Accountable Palliative Care Organizations (APCOs) in some of our nation's communities (we'll explore several of these success stories in future posts). And while building an APCO is a test of endurance, will, and collaboration, the process of developing an APCO is stalled more frequently by the slow, fitful, and fragmented process of acquiring the palliative medicine "intellectual capital" requisite to an APCO. A Medical Staff Development Plan (MSDP) will serve as a management guide for the alignment of the physician staffing plan with the Hospice strategic plan.

The MSDP will allow a hospice to:

• identify the opportunities and risks of the current medical staff complement relative to the development of a community APCO ;
• define a reasonable range of investment required to meet recruitment needs; and
• demonstrate the strategic and proactive thinking of hospice/palliative service senior leadership to the community, its hospitals, and other key stakeholders.

The MSDP comprises five sections:

1. Community Assessment of palliative care practices - identifies improvement opportunities and provides competitive intelligence about peer and neighboring programs,
2. Three-Year Staffing Plan - translates community needs into physician staffing requirements and associated financial commitments, 
3. Responsibility Chart and Professional Performance Profile–these tools enable leadership 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, 
4. Compensation Plan –recommends physician compensation models to produce desired physician behavior and translates administrative, supervisory and teaching (AS&T) activities for physicians into fair and reasonable compensation ranges, 
5. Recruitment Plan - the articulation of "community hospice and palliative care" practice opportunities that attract talent and fill competency gaps.

Securing executive/Board support for building a HPM staff is easier when it's the result of a well-thought out, comprehensive and strategic plan that pegs recruitment to milestones.

Building Blocks of a High-Performing Hospice Medical Staff

I'm asked from time to time what makes for a better- performing hospice medical staff. I'm unsure that there is a straightforward answer. The strategy of hospices building medical staffs is a recent and uncommon practice. Uncommon because the median daily census (in 2010) of U.S. hospices was just over 50, and more than three-quarters of hospices admitted fewer than 500 patients annually. Hardly sufficient scale to employ a single full-time physician, let alone a medical staff of five or more. By one rule of thumb oft cited for physician staffing levels (1 FTE per 100 ADC), only 18% of the U.S. hospices would consider employing a full-time HPM physician.

 

Those who have closely followed other health care sectors, such as home health and infusion therapy, are quick to point out that consolidation swept rapidly through these sectors once reimbursement was tightened or reformed, and sub-scale agencies found that size did indeed matter. Will hospices follow a similar pattern? I wouldn't want to wager a hospice's existence against it. So the hospices of the future will likely be larger. And with size comes the need for a medical staff structure that enables access and quality.

 

The structure may vary from hospice to hospice, but most will arrive at the right structure by careful and thoughtful building of the medical staff. Here follows, from our study, the eight building blocks.

 

• Create full-time “blended” practice opportunities that attract and retain HPM physicians
• Develop bench strength to account for volume fluctuations, departures, back-up coverage
• Amass “intellectual capital” for an infrastructure that supports an effective and efficient medical staff
• Deploy hybrid compensation models to align physician and hospice incentives, and reassess at least annually
• Maintain relentless focus on capturing information on physician activity to provide timely and constructive feedback and aid performance management
• Clearly articulate expectations among medical staff practitioners, medical leadership, and hospice management
• Create virtual organizational structure to extend influence of medical staff into greater community to reduce fragmentation of late-life care
• Foster an unswerving commitment to performance improvement to minimize inappropriate practice variation, reduce regulatory risk, and win the confidence of referring sources.

 

We'll examine, over the coming months, each of these building blocks with a little more precision. As always, your comments are invited.

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.

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.

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.

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.

 

 

 

 

A Closer Look at San Diego Hospice (continued)

Contributor Shelley Sansbury responding to comment (below) about CEO's effort to change culture:

Please be assured my intention was not to cast aspersions on anyone. Rather it was to question the necessity of the decision to shut down the very highly regarded San Diego Hospice and Institute for Palliative Medicine in the wake of a Medicare Post-Payment Review of 149 patients.

What you call a 15 year long cultural disregard for the compliance requirements of Medicare mischaracterizes the Open Access policy pioneered by HSDIPM and now employed by more than one in four hospices throughout the country. Medicare eligibility rules clearly do not allow hospices to serve patients who seek curative care, and both the hospice physician as well as the patients’ physician must certify (and periodically re-certify) that the patient is terminal with a prognosis of less than 6 months to live. Within this framework however hospices are permitted to establish their own policies, procedures and criteria for admission and discharge. Whether a patient has a willing and able caregiver available at home can affect whether a hospice accepts or declines to serve a patient who meets all Medicare Hospice eligibility requirements. Abundant research has examined restrictive enrollment policies as barriers to hospice care. (The Debate in Hospice Care, J Oncol Prac, May 1, 2008: 153-157 http://jop.ascopubs.org/content/4/3/153.full). It appears to me SDHIPM's efforts to maintain an Open Access policy is commendable. You ascribe the fate of this organization to a new CEOs attempt to change the culture, purge the executive team, but it was too late…for what? Too late to manage to achieve proper alignment between a commitment to provide the best possible hospice care and Medicare regulatory compliance, an intention the executive expressed in a Nov 13 press report.

I am familiar with the financials, as reported to the CA Office of Statewide Health and Development (and available to anyone with an internet connection). In 2011 this hospice, with an annual unduplicated census of 4,665 patients spent $320K in palliative radiation therapy alone. In total for 2011, net operating expenses of $81M exceeded net patient revenue of $71M. Non-operating revenue including community support such as “donations and contributions” amounted to $12.5M, producing a positive total fund balance.

Another interesting item included in this report is the 78,375 “Medicare Reportable Hours of Volunteer Services”. While this may be of little relevance to the bankruptcy court, it is, and I hope you would agree, a genuine asset, and perhaps one more small reason to hope that those involved in the governance of this voluntary non-profit organization would muster the devotion to emerge from Chapter 11, rather than permanently abandon operations and put an end to the mission on which the organization was built.

 

A Closer Look at San Diego Hospice, Part 2

Posted by Blog Contributor Shelley Sansbury, health care strategist and former hospice and home care executive

 

Here are the facts according to 2011 SDH Annual Report furnished to the state. (Please note these data exclude services provided to patients in the SDH Acute Care Center, the license for which is in suspense.) SDH admitted 3,759 patients to hospice care in 2011. Including patients already on service their unduplicated census for 2011 amounted to 4,665. A total of 3.157 deaths occurred (67.5%). 543 non death discharges were reported. including 51 for whom prognosis was extended. The report specifies that 4,505 patients were actively served, and this unduplicated census accounted for a total of 363,629 Total Patient Care Days, including 346,350 Days of Routine Home Care (95.2%) and 12,059 Days of Inpatient Care (3.5%).

 

One of the measures I believe is useful in an assessment of a hospice is resource consumption as expressed in visits per patient-day

 

Discipline	Visits	Costs	Cost per Visit	Visits per Patient	Visits per Routine Home Care Day
RN & LVN	77,017	$17,743,679	$230.39	17.1	0.22
Social Services	22,435	$3,520,629	$156.93	5.0	0.06
Hospice Physician Services	23,930	$3,808,858	$159.17	5.3	0.06
Homemaker and Home Health Aide	60,020	$1.286,740	$21.44	13.3	0.17
Chaplain	16,968	$1,951,767	$115.03	3.8	0.05
Other*	0
Total	200,370			44.5	0.58

 

 

A review of the financial data for SDH represents what one might expect of an eleemosynary organization, with a service mission. That is, an operating loss subsidized by non-operating income, including memorials, donations, gifts and grants. Although the 28.2 % administrative cost burden seems possibly excessive,  nothing in this report suggests anything other than the performance associated with an industry leader.

 

 

REVENUE
Medicare	$104,918,252	83.3%
Medi-Cal	$12,022,848	9.6%
Other 3rd Party	$7,274936	5.8%
Private Pay	$1,413,167	1.1%
Other	$337,818	0.2%
Total Gross Patient Revenue	$125,898.449
Total Write-offs & Adjustments	<$54,722,163>
Net Patient Revenue	$71,176,286
EXPENSE
Visiting Services	$30,150,474	37.2%
Admin & General	$22.810,068	28.2%
Inpatient General Care	$8,915,012	11.0%
Hospice Service Cost Centers	$11,221,369	13.9%
Other Costs	$5,059,371
Total Operating Expenses	$80,980,525
Net Operating Margin	<$9,804,239>
Non-Operating Revenue including Memorials, Contributions, grants, etc.	$12,471,646
NET INCOME	$2,667,407

 I invite your comments. Anything extraordinary I'm missing?