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.

Leadership Competencies in Exemplar Late-life Communities

What competencies are common among the leaders in exemplar palliative care communities, I'm asked from time to time. At the risk of oversimplifying, I'll suggest three

These community leaders, whether professional managers, physicians, or nurses, are particularly skilled at envisioning, energizing, and stimulating a change process that coalesces communities, patients, and professionals around new models of late-life care. These leaders have an uncanny ability to align their own priorities with those of the organization and the needs and values of the community. Call this a transformation competency.

These leaders display the ability to use metrics and evidence-based techniques to hold stakeholders to high standards of performance, using force of personality rather than the power of one's position. These leaders also understand the formal and informal decision-making structures around late-life care. In other words, they are adept at execution, translating vision and strategy into optimal organizational AND community performance.

And, these leaders are competent at building and sustaining relationships that evolve into networks, and take a personal interest in coaching and mentoring others. Put another way, these leaders possess exceptional people skills.

What competencies have I overlooked? I'd like to hear from this blog's readers.

Improvisational Nature of Palliative Care , and APCOs

I'm often asked why the Accountable Palliative Care Organization (APCO) model is vital to the success of palliative care programs. There are many reasons, of course, but here's one at or near the top of my list. Currently, there is no third-party reimbursement specific to the provision of palliative care, although palliative services are often billed in other reimbursement categories, most frequently, the hospice or home health benefit, and physician or nurse practitioner consultation services (in the hospital, long-term care, or home settings). In addition, there is no regulatory structure or standard-setting body for palliative care (although JCAHO has recently introduced proposed regulations and the National Quality Forum compiled in 2006 a compendium of 38 preferred Practices in Hospital Palliative Care). (http://www.qualityforum.org/publications/reports/palliative.asp ).

The absence of targeted reimbursement and regulation is reflected nationally in the improvisational nature of palliative programs. The Accountable Palliative Care Organization (APCO) offers a structural model that improves the odds for success for a program’s sponsor. Improvisation does not have to mean trial and error, or fitful starts in a program's development.

An APCO provides the structure that brings together professionals to transfer knowledge across settings and disciplines, and the technical capacities through which staff across disciplines and settings are trained in palliative care- specific techniques and tools.APCOs have been successful models for improving delivery of chronic and end-of-life care because their characteristics encourage processes of care that are:
Timely – delivered to the right patient at the right time (early identification of patients)
Patient-centered – based on the goals and preferences of the patient and family, articulated in goals of care conversations
Beneficial and effective – demonstrably influencing important patient outcomes (place of death, intensive care utilization, transitions between settings and providers)
Accessible - available to all who are in need and who could benefit (multiple entry points into palliative care continuum, and absence of barriers related to reimbursement and prognosis).

After all, aren't these processes of care all program sponsors strive for. Yet, so many of us struggle in developing successful programs. I'd like to learn your thoughts.

Advanced Palliative Care Communities (APCCs) - What Distinguishes Them?

What is it about Advanced Palliative Care Communities (APCCs) read here that distinguishes them from other communities (or regions) when it comes to providing care to those with end-stage disease? One is the presence of an organized provider network collaborating on the delivery of palliative care in many settings of care throughout the community. Another is the documentation of, and adherence to, patient preferences. Think POLST or similar tools. Surely, these attributes do not come about on their own. We’ve looked more closely at the deployment of palliative medicine specialists in these communities (APCCs) and have found greater numbers (than in other similar communities) of physicians practicing palliative medicine and greater use of those physicians in clinical consultative roles in multiple settings throughout the community. What does not matter, we've found, is the organizational sponsor (or employer) of these palliative medicine physicians.