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.

Exemplar Hospitals for Late-Life Care

Geisinger Medical Center, in Danville, Pa., has become a favorite of President Obama when he discusses models of health care delivery worthy of emulation (so has Mayo Clinic and several others, but that's a subject for another post). It set me to wondering: how well does their (Geisinger) model translate into late-life care? Using data of palliative outcome measures drawn from the Dartmouth Medical Atlas, the research staff at DAI Palliative Care Group compiled a Hospital Palliative Performance Profile for Geisinger. Not unexpectedly, Geisinger produced a Palliative Performance Score of 105, earning it an A Grade and Exemplar Hospital status. Geisinger scored well in deaths by location (its patients were 8% less likely to die in the hospital than the national average) but where its performance stood out was in avoiding use of the ICU during a decedent’s last six months of life (Geisinger’s rate was less than half of the national average).

The DAI staff identified at least two other Exemplar Hospitals in Pennsylvania – Lancaster General Hospital (Lancaster) and Susquehanna Health System (Williamsport).
Susquehanna’s score dazzled us – 130, one of the highest in the nation. There are seven palliative outcome measures used to develop the Performance Profiles – Susquehanna scored better than the state and national averages in six of seven measures. For one measure, hospital days per decedent during the last six months of life, Susquehanna’s experience was nearly 40% better than the national rate. Surely, there must be lessons to be learned here, practices to be emulated.

Could it be that an Accountable Palliative Care Organization (APCO) has evolved over the past decade, under the leadership of a chief palliative care officer in the Williamsport community? Is there a “bellwether” HPM practice which contributes to the Hospital’s exemplar status? Suffice it to say, for the present, that there are exemplar hospitals and communities whose performance in late-life care suggests that there remains considerable room for improvement for most hospitals, and in most communities.

Closing the Performance Gap in Palliative Care by Reducing Clinical Variation

The Dartmouth Medical Atlas gives us a compelling portrait of the variations in practice in late-life care. It also offers insights into the palliative performance improvement opportunities in communities.


How wide are the variations? Let’s take a look at Charlottesville, Virginia, an area of about 100,000 residents, with an academic medical center and a community hospital, a large not-for –profit hospice, and plenty of smaller hospices. According to the DAI Palliative Performance Profile (drawn from the Dartmouth Medical Atlas), Charlottesville earned a B grade for its late-life care practices. Respectable, for sure, but short of exemplary. What’s the difference between respectable performance and that of the top 10% performers? Consider the following: in Charlottesville, 32% of Medicare decedents died in a hospital. That’s better than the state average, yet 25% higher than residents of a community in the top 10%. In other words, a Charlottesville resident is 25% more likely than a resident of a high-performing community to die in a hospital than at home. That same Charlottesville resident is 40% more likely to have spent 7 days or more in a hospital during the last six months of life than someone in a top-performing community. Considerable room for improvement, I think you'd agree, and yet Charlottesville's performance is better than most communities across the nation.

Tightly integrated delivery systems have proven to be the most effective in reducing clinical variation. Because of their structure, these delivery systems are adept at disseminating evidence-based practices. It is time that hospice and palliative care leaders accelerate collaborative efforts to create networks with greater potential to reduce clinical variation in late-life care. What better opportunity for HPM specialists to take the lead?






　

Is Palliative Care A Disruptive Innovation in Health Care?

It's been a short (or is it long?) ten years since the September-October 2000 issue of Harvard Business Review published the article "Will Disruptive Innovations Cure Health Care?  In that piece, the authors (Clayton Christensen, Richard Bohmer, and John Kenagy) argued that powerful institutions fight simpler alternatives to expensive care because those alternatives threaten their livelihoods. If history is any guide, the authors posited, the health care system can be transformed only by creating new institutions that can capably deliver lower-cost, higher-quality, and more convenient care, rather than attempting a tortuous transformation of existing institutions (read that as acute-care hospitals) that were designed for other purposes. They went on to comment that our major health care institutions have together overshot the level of care actually needed or used by the vast majority of patients. Has much changed  during the intervening decade? And, it set me to wondering, is  palliative care  considered a disruptive innovation?

James Cleary, MD (palliative care chief at the University of Wisconsin Hospital and Clinics), referred to hospital-based palliative care as a disruptive innovation in a 2008 keynote address to an audience of hospice and palliative care professionals. And as one considers that disruptive innovations "sneak in from below",  start by meeting the needs of "less-demanding customers", and enable "less-expensive professionals to do progressively more sophisticated things in less expensive settings", the case sharpens  for palliative care as a disruptive innovation.

So why doesn't palliative care always feel like a disruptive innovation? Surely one reason
is that new organizations to do the disrupting have not sprung forth  the palliative care sector. That is likely to change soon, as  the formation of Accountable Care Organizations (ACOs),  encouraged by the health reform bill,  reconfigure the delivery models of health care over the next decade. And within the ACOs will emerge Advanced Palliative Care Organizations (APCOs), proven to be  successful models for improving delivery of chronic and late-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).

I invite our readers to weigh in.  Is palliative care a disruptive innovation? And if so, what steps will best advance its influence within the larger health care system?

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.

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.

Rational Discussion, or Discussion about Rationing?

In a recent post on the Health Beat blog, Naomi Freundlich comments that although life-expectancy is increasing, so is the incidence of multiple medical problems and chronic disease in the elderly. Which, once again, raises the question of how Medicare costs could possibly be tamed?

The author goes on to say that "we also face a more personal, moral challenge as life expectancy continues its relentless march forward: We must begin to separate new treatments that will help older people age better—avoiding long-term disability, dementia and frailty—from those that merely extend life at any cost. We can only do this by having honest conversations about end-of-life issues; in medical schools, among families and between doctors and patients. "

The Urban Institute, a nonpartisan research center, found in a 2009 report that the government could save $90.8 billion over 10 years by better managing end-of-life care. And, the Institute further concluded that much end-of-life spending isn’t sought by patients and goes against their families’ expressed preferences.

$90 BILLION dollars. Makes me wonder who would be receiving that money if it were spent. Surely, much of it would go to hospitals. And some of it to physicians. Makes me wonder also if this subject can be discussed rationally, rather than it being a discussion about rationing.

Can Hospice and Palliative Care Escape the R Word?

The question Why are Referrals to Hospice Slowing? seems to be making the rounds these days.
Misconceptions about hospice and palliative care have abounded well before the latest efforts to refrom the health care system. How else to explain the persistent and continuing reticence to refer to, and accept hospice services, in most US communities. What's different today is that the skeptics of hospice and palliative medicine are more vitriolic than their predecessors, and their talking points (arguments) are more vivid - "death panels, socialized medicine".
I served as the chief executive of a hospice affiliated with a highly-regarded academic health center in the 90s, and the reasons then were abundant for the low referral rate to hospice: patients were referred to academic health centers because they wanted to avail themselves of the most sophisticated medical care for cure; the attending physicians were providing palliative care; the patients' religious/cultural beliefs made them unready for hospice, etc. We've all heard them before, and we still hear these reasons now.
It's just that now, in the context of health reform, palliative care, for some, is considered 'rationing."
And it gains credence because there is so much money in late-life care.

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.