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.