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.