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.

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.

Why Intellectual Capital Matters to Growth of Palliative Care Programs

Our experience and research within palliative care have shown that "program champions" have been successful not so much because of what they bring to the role, but what the organizational program sponsor brings to the program champion. Certainly, a multi-talented physician champion increases the chances of success, but we've found it is the tools (intellectual capital) that she/he has to work with that are the primary determinants of success. The physician starting a practice (which is essentially what the program champion will be doing) needs to have strong clinical skills and knowledge, to be sure, but will need also to create goodwill (to build solid referral patterns), establish business processes, workflow, and databases, and generate revenue to produce a sustainable program. Organizational sponsors typically don't possess this intellectual capital specific to palliative care, and so, champions often find themselves stretched to produce results with little "infrastructure". As a result, the program champion finds her/himself spending time toward "marshalling" resources, at the expense of "deploying" those resources to grow the program.