Hospice and 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. A recent post described the current structure of the hospice industry. 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.

Accountable (Palliative) Care Organizations - A Call for Comments

Blogs Pallimed and GeriPal have posted very recently about an opportunity to influence the development of  an organizational model that some consider to be a prototype of the next decade's health care delivery system. Accountable Care Organizations (or ACOs).    The shift accountable care organizations will bring from pay-for-volume to pay-for-value — and their focus on total population management, closely aligned incentives and a degree of coordination among providers not typically seen in most markets — cuts to the heart of  the health care institutions within most communities . In the cards, some suggest, are:  fewer hospital admissions, shorter lengths of stay, fewer emergency department visits, and fewer procedures and tests. Hospice and palliative care advocates, take note, this is our opportunity.
There is a special request for comments regarding certain aspects of the policies and standards that will apply to ACOs participating in the Medicare program under section 3021 or 3022 of the Affordable Care Act. The request can be found at regulations.gov under the document number: CMS-2010-0259-0001.


The dealine for comments is December 3rd, so there is little time to act.  Diane Meier has offered some guidance in formulating a response to three main questions posed in this call for public comments. Here are her possible talking points that you can consider putting in your comment:

Question 1: How should we assess beneficiary and caregiver experience of care as part of our assessment of ACO performance?

•Require evaluation of patient and family goals of care, using for example POLST and advance care planning

•Determine patient-family recall of discussions about care goals, and degree to which care actually received is concordant with goals

•Require access to quality palliative care and Medicare-certified hospices as a condition of participation in an ACO.

•Assess penetration of and receipt of palliative care among high need high cost patient populations across diagnostic categories.


Question 2: The Affordable Care Act requires us to develop patient-centeredness criteria for assessment of ACOs participating in the Medicare Shared Savings Program. What aspects of patient-centeredness are particularly important for us to consider and how should we evaluate them?

•The most important aspect of "patient-centeredness" is the degree to which informed and achievable patient and family goals for care are elicited, documented in an accessible and retrievable manner, and actually followed in the care plan.

Question 3: In order for an ACO to share in savings under the Medicare Shared Savings Program, it must meet a quality performance standard determined by the Secretary. What quality measures should the Secretary use to determine performance in the Shared Savings Program?

•Quality measures should include advance care planning; occurrence and timing of palliative care services among appropriate patient subgroups; occurrence and timing of hospice services among appropriate patient subgroups; symptom burden; patient confidence that someone on the team knows them and can be reached after hours; degree to which patients families believe they know what to expect and are prepared to handle their illness; degree to which family needs are assessed and addressed among appropriate patient subgroups

Dr. Meier makes clear that the goal of our comments should focus on making the point that an ACO must require access to quality palliative care for its sickest high need and high cost patients in order to assure that care is directed by and concordant with patient and family goals, and not by strong ACO incentives for cost containment.

There is little time to act. Just click here and submit a comment. To make your lives a little easier, the following is a draft outline that you can use in your comment:

1.Introduce yourself as palliative medicine clinician or health professional.

2.Define palliative care as medical care focused on best possible quality of life, delivered from point of diagnosis of serious or advanced illness whether the goal of care is cure, life prolongation, or achieving a peaceful dignified death. In practice, consists of expert assessment and treatment of symptom distress including pain, anxiety, and depression; conduct of in-depth discussions with patients and families to establish achievable care goals and a care plan that meets those goals; and commitment to continuity of care and relationships across the many care settings that seriously ill patients must traverse over the course of an illness. Palliative care includes end of life care (hospice) but is not limited to it- it is especially important among Medicare and Medicaid beneficiaries with advanced disease and/or multiple chronic conditions with functional impairment- a group who are not predictably dying and who may live for many years with a significant burden of disability and medical needs.

3.The core strategy of palliative care is to help informed patients and families determine their achievable goals for care and then helping to make sure that medical care received helps patients achieve those goals.

4.The goal of ACOs is to incent quality and not quantity and to coordinate the full range of providers. Because of ACO-associated changes in financial incentives that will reward efficiency and "doing less", the risk of undertreatment- reduced access to needed care- and consequent poor quality of care is greatest for high need high cost patients. To counter that risk, ACOs should be required to provide access to specialists trained in care of this complex high need patient population across diagnostic categories, and specifically trained in the skilled communication necessary to elicit achievable care goals throughout the course of illness. Providers with this training work in palliative care programs (mostly hospital-based) and in hospices.


More on Accountable Care Organizations, and the role of hospice and palliative medicine, in future posts.

What Might A "Sought-After" Hospice and Palliative Medicine (HPM) Practice Look Like?

At a recent forum addressing the subject of HPM physician performance, one of the panelists asked the above question. During our study of bellwether practices, we've asked ourselves a similar question - how does a HPM practice create value? While our research has been far from exhaustive, our findings offer some insight into this question. A post last year on this blog offered an early take on this question.

Let's revisit this question, this time from a post-reform legislation view.

Unarguably, HPM practices are not, and will not be, sought after because of their revenue-generating capacities, either from direct patient care services (home visits, hospital consults, inpatient hospice management) or ordering tests, performing procedures, or utilizing a hospital's facilities. To be sure, hospital palliative consults have proven to be effective cost avoidance services for hospitals. This effectiveness, however, is subject to the law of diminishing returns, in that the "savings" are front-loaded in the first few years following introduction of the palliative care service. Once the "new" standard of care is firmly in place, savings become more difficult to squeeze out of the palliative care service. Some counter that eliminating the palliative care service would return costs to the hospital. While that may be the case to some extent, I don't know of many health care CEOs and CFOs who would "recount" savings that had already been accounted for.

The Dartmouth Medical Atlas has shown that there is enormous variation in late-life care, AMONG and WITHIN communities. In fact, it is not unusual to find wide variation in practice from one IDT to another within a hospice provider. Reducing clinical variation, simply put, is not a quality improvement priority for most hospices and palliative care organizations. In future posts, we'll take a closer look at the clinical variation question.

Tightly integrated delivery systems have proven to be effective in reducing clinical variation. These delivery systems may soon serve as models for the development of Accountable Care Organizations (ACOs). A recent article highlighted Dartmouth-Medical Clinic, a 900-physician group practice in New Hampshire, which has earned $13 million so far in the Medicare Physician Group Practice Demonstration, the model for accountable care organizations. The Clinic focused on reaching out to patients with chronic illness, improving coordination of care for patients transitioning between care settings, and more aggressively monitoring patient between physician visits.

For these activities, surely HPM physicians, palliative care nurse practitioners, and hospices play a vital role. A network of physicians and palliative care clinicians will be extremely valuable to these ACOs. Why? Because these networks will already be in place to provide timely, patient/family centered, and evidence-based care to those with advanced illnesses. Such care will likely cost less, as fewer days are spent in ICUs and hospitals, and more at home, under hospice and palliative care.

You may be thinking, ACOs aren't called for in the health reform legislation until January 2012.
Keep in mind, building an effective delivery network is a years-long process, so yesterday was the best time to start. There are at least three steps, each of them formidable, to building a tightly integrated network to deliver advanced-illness care. These are:

- applying clinical protocols proven to reduce clinical variation,
- electronic capture and transfer of clinical information across settings,
-"internal transfer" of reimbursement.

Future posts will look closely at each of these steps, as well as the value that a high-performing hospice medcial staff brings to the formation of a HPM network, and how HPM practices may best position themselves to become the "go-to provider" for late-life care.

Gentiva-Odyssey - Who Will Be the Beneficiaries?

I've suggested in the past that the hospice industry is sub-scale (too many small providers) so I've been asked recently if the news about the Gentiva acquisition of Odyssey marks the beginning of a consolidation that will benefit the delivery of hospice services in the US.

The recent business transaction between Gentiva and Odyssey is a blockbuster deal (or as some analysts put it, a game-changer) not only because of the dollars involved (a billion of them) but also because it involves the combination of a for-profit home health provider with a for-profit hospice.

Several points struck me:

-Gentiva will be under great pressure to make this deal work because it expects to raise $1.1 billion in NEW DEBT financing to fund the purchase price and refinance existing debt. Such financial pressure encourages management decision-making where patient enrollment trumps patient service.
-Identifying synergies (not to be confused with economies of scale) between home health and hospice has been elusive. It's probably why there haven't been such large-scale combinations to date, and why even small-scale home health/hospice collaborations (either for-profit or not-for-profit) have been few and far between. That said, Gentiva's management has had a solid track record and may be up to the task of capitalizing on these elusive synergies.
-Health care (especially home and hospice care) is local, and after the transaction is completed, the key question will be: can a home health-hospice behemoth better advance (than other organizational delivery models) the provision of palliative care to those with chronic or advanced illness? To the extent that the new Gentiva/Odyssey entity may be able to develop accountable palliative care organizations (APCOs) within the communities it serves, then it may be worth the effort.

I'm curious to learn your thoughts.

Accountable Palliative Care Organizations (APCOs)

From time to time, clients inquire if there is a single factor which keeps communities, in general, and hospital/health systems, specifically, from realizing the full potential of palliative care. Our analyses of the Dartmouth Medical Atlas suggests to us that HOW communities are ORGANIZED to deliver and distribute palliative care may be the single most important determinant of success.

Drawing a composite picture of a hospital’s (and community's) palliative care performance from palliative outcome indicators can reveal lots about performance in meeting the needs of those with advanced illness. Our study of better-performing communities identifies several attributes shared by these exemplar palliative care communities (much has been written recently about one of these Exemplars - LaCrosse, Wisconsin). These shared attributes are:
• Multiple Points of Patient Access
• Multiple Sources of Reimbursement and Mechanisms to Enable Internal Pricing and Transfers
• Chief Palliative Care Officer
• Protocols/Tools Span Settings of Care
• Relentless Collection of Data and Focus on Accumulating and Disseminating Knowledge of Best Practices.

We refer to virtual structures possessing these attributes as Accountable Palliative Care Organizations (APCOs). In coming posts, I'll offer more detail on why these attributes matter, and why APCOs are so difficult to develop. In the meantime, I'm curious to learn your thoughts, and how your assessment of current late-life care practices in your communities confirms or refutes this organizational model.

Accountable Palliative Care Organizations (APCOs)

Recently I was asked by a client to describe the role of Accountable Palliative Care Organizations (APCOs) in creating exemplar practices around "late-life" care within a community (see here for a previous post describing exemplar communities). The client is situated near a shopping mall that had been struggling until it recently brought in a major department store - a topic which had been a subject of an earlier conversation that day. An APCO, I replied, is like an "anchor tenant" of the palliative care community, setting norms to encourage the free-flow of ideas and collaboration, producing enduringly successful communities.

Within these APCOs, physicians , hospices, hospitals, and long-term care facilities adopt measures to blunt harmful financial incentives, thus taking collective responsibility for improving care for those with advanced illnesses (what I'm terming late-life care). Much has been written and commented of late about the role of financial incentives in the health care system, and what provisions in the health care reform bill could bring about better outcomes while containing costs.

I'm curious to learn your thoughts and experiences, as we explore this subject in greater depth in future posts.

An APCO Developing in Asheville?

In a recent post (read here), I commented about the exemplary results of Asheville, North Carolina in the DAI Community Palliative Performance Profile. To learn more, we interviewed Janet Bull, MD, VP of Medical Services for a not-for-profit hospice (Four Seasons) serving the Asheville area.

Some excerpts:

"We are very heavy in physician staffing, and think that is a good real positive," with the physicians mainly out making billable visits to hospice patients and serving as attendings or consultants on about 80 percent of patients enrolled in hospice care, she explains. "They actually paid for themselves last year."

Essential to the palliative care program's success was being clear on what kinds of patients it would see -- or not see. Dr. Bull continues, "We learned early on that we can't be all things to all people. We didn't want to be a chronic pain service or post-acute, post-surgical consultants. We wanted to stay focused on serious, advanced illness, generally for patients with three years or less to live. At Four Seasons, we are all about delivering quality care and looking at measurable outcomes. We take our patient and family satisfaction surveys very seriously.The program emphasizes continuity of care across care settings. From the get-go, we saw patients where they were, and we followed them from one setting to the next."

Integrating the hospice and palliative care departments was also a priority. "Many organizations bump up against the problem of palliative care being viewed as a step-child to hospice. Here we value the great things palliative care brings, and how it complements hospice," Dr. Bull says."We consider ourselves one big team, whether palliative care or hospice, with a lot of interface between the two. Patients can flow both ways between these programs. We used an explicit strategy of building the connections between the two. Some employees serve both programs, and we share resources and administrative tasks, integrating them whenever we can," she reports. "Often at staff meetings we'll have presentations by palliative care leadership or providers, explaining their work to hospice staff. We focus on education, both internally and externally, explaining the differences between hospice and palliative care, and how they complement each other. We inform patients that hospice offers many more services than palliative care."

Seems to me that what we're seeing in Asheville is the early development of an Accountable Palliative Care Organization, led by a chief palliative care officer for the community. Surely, there are other factors contributing to Asheville's performance, but just as surely one cannot underestimate the value of a strong and well-developed medical staff of HPM specialists.

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.

Why Organizational Delivery Models Matter to Effective Palliative Care

There are multiple examples of health systems -- President Obama and health policy makers have cited Mayo, Geisinger, Cleveland Clinic, and others as models for health-care reform -- that consistently and reliably achieve similar results: providing good care at low cost, with high patient satisfaction. Bassett Healthcare, serving the Cooperstown, New York region, is among those others. What these systems have in common, we're advised, is that they are integrated systems that employ their physicians, emphasizing patient-centered care, better outcomes, and prudent stewardship of health-care resources, with accountability for results.

We've looked closer into these hospitals and communities to understand better if this model also produces desirable results around late-life care. We've learned previously that Geisinger has seen exemplay results in its late-life care practices. So we took at look through the Dartmouth Medical Atlas at the formerly named Mary Imogene Bassett Hospital, now known simply as Bassett Medical Center. The Hospital's results in the seven DAI Palliative Outcome Measures earned it an exemplary grade. Patients loyal to Bassett were 20% less likely to die in the hospital, spent almost 40% fewer days than state average in a hospital during the last six months of life , and were more likely to have been under hospice/palliative care. Yet perhaps the most telling is that in their final months, 30% fewer patients were seen more than ten physicians during late- life care. You read this correctly, TEN is the benchmark.

Thus, we find that in another community a tightly integrated health system produces desirable outcomes in late-life care. What remains unclear is what attributes of a tightly integrated health system are most responsible for these results. With that knowledge, these attributes might be replicated elsewhere (as in an Accountable Palliative Care Organization).

I'm curious to learn your experiences and thoughts.

Palliative Medicine - Undercapitalized and Overcommitted

The practice of palliative care, by physicians and advanced practice nurses, has gradually moved into the mainstream of American health care. While there is little debate over the need to improve late-life care, especially within acute and long-term care institutions, there continues considerable discussion over how to best improve it. Unlike most other medical specialties, palliative care is not reliant upon the effective formation of physical capital (diagnostic and therapeutic equipment using advanced technology) for its practice –to the contrary, it is totally reliant upon the effective formation of intellectual capital. Its effective formation is integral to the success of palliative medicine practices.
You’re thinking that palliative care is the lengthened shadow of a practitioner’s knowledge of clinical best practices. And, you’d be on the right track, for the provision of palliative care is based upon one component of intellectual capital, the know-how, skills, and competencies of the practitioners. Whether a practice or program has sufficient number of practitioners to render this knowledge-based care, first-hand, throughout the community, is a critical decision whose studied deliberation can tip the scales in a program’s outcome.
Two other components make up a program’s intellectual capital: one, structural capital (or infrastructure) - those workflow processes (automated or manual), revenue cycle practices, databases, and routines that enable effective day-to-day operations. The other is customer capital - or goodwill to many - the program’s relationship with its referring, and non-referring medical community, payers, partners, and, of course, its patients. The effective formation of these three components leads to the desired result – development and sustainability of the practice, and its affiliated programs.
So, what’s my point about being undercapitalized, you’re likely wondering? Most programs, and by extension the practices that support them, are subsidized by hospitals, hospices, or grants and philanthropy. This support is often renewed annually, thus demanding of the program’s managers a yearly impact statement of the program’s results. Long-term sustainability depends upon revenue generation, a business process oft shortchanged, at best, or neglected, at worst. This structural capital is often borrowed from the parent organization, whose resources, no matter how well intentioned, rarely offer the sharp focus, attention, and insider know-how so necessary to effective revenue capture.
OK, there may be a shortage of intellectual capital, but overcommitted? Palliative care specialists, were they to be queried, would remark that they don’t have sufficient time to develop the program. Programs report either of two situations – that palliative care has been widely adopted as the standard for late-life care in the community, and that there aren’t sufficient qualified staff to respond to referrals, or that palliative care has not sufficiently diffused throughout the community and a stronger referral base needs to be built. In either instance, what's lacking is a critical mass. Hospices provide part ofthe answer. So do hospital-based palliative services. Only Accountable Palliative Care Organizations (APCOs), through their effective formation of intellectual capital, have the capability of providing the entire answer.

Future of Palliative Medicine Practices

Will reform help or hinder the practice of Hospice and Palliative Medicine(HPM)?

Help, if HPM physicians reconfigure themselves into "sought-after practices". The reconfiguration must be willful and carefully planned, and in advance of implementation of national health reform. In other words, bets must be placed now that the health care delivery system will be restructured, and payment for health services will be revamped.

In upcoming blog posts, we'll take a close look at likely scenarios, and how the organizational alignment we've identified as Advanced Palliative Care Organizations will evolve into Accountable Palliative Care Organizations (APCOs). And, we'll examine the likely role of HPM physicians in APCOs, or what we refer to as the emerging role of the Chief Palliative Care Officer. This blog will be one forum for this discussion, so your comments and experiences are invited.

Also, we plan a regular publication (HPM Practitioner) that will offer you insights into "bellwether" practices. An upcoming issue will feature the HPM practice in Grand Junction, Colorado, about which I have posted previously.

From our study and research into best practices of palliative care, we've developed theories of what differentiates exemplar palliative care communities from others. How HPM physicians are utilized is one distinguishing feature. How they are organized is another. And under health reform, how they are paid will likely be another. Think bundling, and the value of a "network of HPM physicians" tightly organized to increase negotiating (with both payors and providers) clout.

As always, your comments are invited.

Accountable Palliative Care Organizations - Mayo style?

As hard as health insurance reform is, compared to health care DELIVERY reform, that’s the easy part, Mayo Clinic CEO Denis Cortese said at a recent presentation to the National Press Club. Mayo has been frequently cited as a model for health care delivery reform by President Obama and others, but the question of Mayo’s value as a model for overall reform has also generated considerable discussion from both sides.

Cortese cited the significant regional variation in medical practice documented by researchers at Dartmouth (and discussed periodically in this blog, see here and here ) , and he listed several factors common to institutions and regions that produce what he called "high-value care": patient-centric cultures; high levels of physician engagement in leadership and change; much higher levels of teamwork, collaboration, and coordinated care; more "connectivity" and sharing of electronic medical records and information; and much greater use of "the science of health care delivery," meaning systematically looking at how patients flow through an organization in order to reduce waste and standardize processes to reduce errors.

These factors, it occurred to me, are similar to the attributes possessed by Accountable Palliative Care Organizations (see here, here, and here). Producing "high-value care" , whether for an acute episode, in an ambulatory setting, or for late-life care, is a formidable challenge. And it is why, if palliative medicine physicians can incorporate into their practices those skills requisite to success in these emerging delivery models, their practices will be highly sought after.

APCOs and Palliative Care Performance

In a recent article Slowing the Growth of Health Care Costs — Lessons from Regional Variation http://content.nejm.org/cgi/content/full/360/9/849 authors Elliott S. Fisher, M.D., M.P.H., Julie P. Bynum, M.D., M.P.H., and Jonathan S. Skinner, Ph.D. describe research findings in which physicians in higher-spending regions were much more likely than those in lower-spending regions to recommend hospital admission for an 85-year-old patient with an exacerbation of end-stage congestive heart failure. And they were three times as likely to admit this patient directly to an intensive care unit and 30% less likely to discuss palliative care with the patient and family. Put another way, differences in the propensity to intervene in such gray areas of decision making were highly correlated with regional differences in per capita spending on health care.

Not surprised, you say. Perhaps one shouldn't be. After all, data from the Dartmouth Medical Atlas has long shown there are huge differences in health care spending from one region to another that are best explained by intensity of practice patterns rather than intensity of illness. This same article goes on to say that a consensus is emerging that integrated delivery systems that provide strong support to clinicians and team-based care management for patients offer great promise for improving quality and lowering costs.

Similarly, our studies of palliative care in high-performing communities (and health systems) have shown that Advanced Palliative Care Organizations (APCOs) possess attributes similar to those of integrated delivery systems, while being led by chief palliative care officers. Who are these chief palliative care officers? Mostly, physicians (sometimes nurses) with training, experience, and expertise in palliative medicine.

What difference can APCOs make? For starters, they can deliver care to patients with life-limiting illnesses that is consistent with the preferences of these patients and their families. Residents of Sarasota, Fla. (a high-performing palliative care community) are nearly 30% less likely than the average American to die in a hospital, and will spend during their last six months of life nearly 25% fewer days in a hospital than the national average.

So why aren't there more APCOs? The answer is complex and will be better addressed in future posts, but let's just say for the moment that one of the reasons is that there is more competition than collaboration among this country's hospices and hosptials. Yet another possible explanation is that there is an acute shortage of qualified HPM physicians who are interested and willing to practice palliative medicine on a full-time basis.

Do Hospices Need Medical Staff Planning?

Hospices are evolving into advanced palliative care organizations (APCOs)in which care spans organizational and professional boundaries and physician services are integrated into a collaborative model that reconfigures a traditional nurse-centric organization,. Such a convergence will, unsurprisingly, strain an organization’s resources and its roles. For organizational strategic considerations, meeting community needs, and regulatory compliance, medical staff planning improves the likelihood of hospice success.

However, shortages of experienced, fellowship-trained, and Board certified Hospice and Palliative medicine (HPM) physicians and the growing need for such physicians in specific practice areas (long-term care, hospital consultative, home visit) will lead to increased frustrations among hospice executives, clinical staff, and physicians and hinder the achievement of hospices’ strategic goals.

Given the “not if, but when” trends surrounding the role of HPM physicians in a community’s end-of-life care practices, hospices that initiate a medical staff planning process in the short term will provide themselves with the time required to muster and develop the necessary financial and other resources to align their medical staff plan with their strategic objectives. Such a medical staff resource planning service will also help identify potential opportunities to enhance market position through physician recruitment.

Will Health Reform be Kind to Palliative Care?

Were I a betting person, I'd wager a princely sum on our getting within the next year a major reform of the health care system. Why am I so confident? Because the auto makers financial crisis will highlight the nation's health care cost issue. The "car czar" will make sure of it. And while the implications and ramificiations of "reform" will undoubtedly be wide-ranging, I've given to wonder what reform will mean for palliative care in general, and palliative medicine practices specifically. Mounting signs suggest that reform will be, indirectly, unkind to palliative care. In upcoming posts, I'll offer my take this subject. In the meantime, I invite yours.

Exceptional Palliative Medicine Practice Opportunity

Earlier this year, I was asked by a journalist who covers the hospice industry to comment on the future practice opportunities awaiting physicians interested in practicing palliative medicine.
I commented in that piece that the traditional role of hospice medical director was in the midst of evolution, to which I added that was a positive development since this traditional role would not suffice (no matter how well paying) in attracting talented physicians to the field. Some interpreted my comments as an assault on the fine work done by hospices in this country. On the contrary, I see physicians serving as the keystone for the development of Advanced Palliative Care Organizations - below, I describe a current practice opportunity with which I'm working that typifies the sort of position that will become prevalent in communities across the US.
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You'll showcase both your clinical expertise and business savvy as you implement clinical and business development strategies for our client’s palliative care service. The service was initiated in 2005, backed by several years of assessment and development, and promises to redefine how end-of-life care is provided in the flagship hospital of one of the most highly regarded health systems on the East Coast. This service has generated significant interest among key stakeholders, who are eager to integrate these palliative care protocols into their practices.

This hospital-based palliative care service accounts for one of the most important strategic initiatives over the next 24 months. While some strategy is in place and activities have been underway for some time (currently about 70 consults/month), you'll put your personal stamp on these programs as you expand development efforts and provide palliative services to patients in acute and long-term care settings.

The success of this program will provide impetus for more palliative services within the health system.

What You'll Bring to the Table

MD or DO, Board certification in primary specialty and palliative medicine
Experience in delivering hospital-based palliative care services, including a successful track record of advancing palliative care programs through clinical development.
Deep knowledge of clinical practice guidelines for quality palliative care and understanding of quality improvement methodology
Ability to effectively lead, manage, and participate on multi-disciplinary teams.
Strong interpersonal, public speaking, written communication skills.

Your Unique Opportunity

This position offers many unique benefits:

Stability – the palliative care service has received senior management (of both the sponsoring hospice and health system) authorization, and has been well received by clinicians throughout its introductory period

High visibility -- your visibility to hospital executive team is a "given;"

Exceptional work environment -- each employee is expected to contribute toward shared goals, to sustain a working environment that is team-oriented, professional, challenging and friendly.

Career development -- your purview will include both development and implementation, and an opportunity to develop a thriving practice in palliative medicine throughout the health system

High impact -- your success in building out the palliative service within the will enhance our client’s reputation as a leading provider of care for those with life-limiting illnesses

About the Organization

One of the largest not-for-profit hospice and palliative care enterprises (more than $60 million in patient service revenues) serving multiple counties in Virginia and the DC metropolitan area. This organization is highly regarded in its communities for its end-of-life care, and receives considerable philanthropic support. It serves daily more than 600 patients through its certified hospice, inpatient hospice unit, and its facility-based palliative care service.

Compensation

Total earnings potential will top $150,000
In addition to a salary guarantee, this position offers a comprehensive array of benefit programs designed to meet the needs of you and your family, including medical, dental, vision, STD and LTD insurance, 403(b) investment options, paid vacations and holidays, and employer-paid professional malpractice insurance,

More About Your Role

Reporting to the Senior Medical Director, in addition to direct patient care, your activities will include:

Identifying tension points to aid in marketing palliative care services to clinicians
Developing strategies to build sustaining relationships with community partners
Establishing palliative care as a recognized service within the affiliated hospitals, nursing homes, and community clinics
Serving as physician member in education and training of clinical staff, and oversight of palliative program staff
Planning timetables and budgets for program development.
Traveling to clinical affiliates throughout the service area to deliver and oversee palliative care services

Keys to Success

To excel in this role, you will:

Apply your clinical knowledge of palliative consultations and experience with program development to drive the palliative care service forward quickly
Leverage your understanding of the nuances of success in the development of palliative care programs
Be recognized throughout the hospital as the leader (subject matter expert) of palliative care

Hospital Palliative Performance Profiles

Since 1996, the Dartmouth Atlas of Health Care has tracked patterns of health care delivery, practice and quality across the country. Its massive pool of national, regional, local and provider-level health care utilization and cost data, derived from the Medicare database, has documented striking geographical variations in the delivery of health care services. But it has also changed our understanding of the efficiency and effectiveness of health care delivery and demonstrated that more medical care does not necessarily mean better care—that the wide disparities in health care spending and utilization do not track with measurable improvements in health care quality. In fact, higher utilization at the end of life may represent both harm to patients and billions of dollars in wasteful and unnecessary health care spending.

The Dartmouth Atlas Project, founded by Dr. John E. Wennberg, is based in the Dartmouth Institute for Health Policy and Clinical Practice at Dartmouth University. Its databases are used by health care policy-makers, analysts, health care executives, researchers, and, increasingly, palliative care advocates seeking to plan or justify the need for palliative care services to help their hospitals better manage these high-need, high-cost, high-utilization patients.
“Concern about overly aggressive care for patients at the end of life has sparked increased interest both in palliative care and in aligning the kinds of services provided to dying patients with their well-informed preferences,” the report states. “Patient wishes may have less influence on intensity of care than the practice patterns of the hospital where the care is given.”

Taken together, these figures start to sketch a picture of how much potentially futile or ineffective care a hospital or a region provides to patients during their final months of life or during the hospitalization in which death occurs—as well as creating an opportunity to compare performance on these variables among peers.

Our analyses show there is great variation in end-of-life care across regions and states. Digging deeper, our research group has identified that those hospitals with high performance scores (100 or above) have adopted advanced palliative care organizational (APCO) principles in which there are what we refer to as “learning communities”. This learning community is essentially a group of palliative care stakeholders who "join" together and are driven by a desire to share problems, knowledge, experiences, insights, templates, tools, and best practices around palliative care.

I'm interested to hear from those involved in learning communities sponsored by APCOs.

Advanced Palliative Care Organizations -An Organizational Model to Distribute Palliative Care

Hospices are especially adept at managing patients close to the end-of-life. My study suggests there are two reasons - because the number of such patients that hospices serve is so large (more than 50% for many hospices) AND because the most challenging patients (clinically and financially) are those with lengths of stay of 10 days or less. Several research studies have found that the most costly periods of care, under the hospice benefit, are the FIRST five days of enrollment on the hospice benefit and the LAST five days of life. So it's natural to expect that hospices will become proficient in managing "short-stay" patients.Currently, palliative care in this nation is organized, and thus delivered, around the hospice benefit. No question, greater accessibility to better end-of-life care has resulted since Medicare introduced the hospice benefit. I believe most of us would agree,however, that palliative care applies to many more patient populations than those fast approaching end-of-life. How can we best assure that chronically ill populations benefit from palliative care? By reorganizing, around Advanced Palliative Care Organizations, how health care is provided to those with life-limiting diseases.