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.

What Do Hospice and Palliative Medicine (HPM) Physicians Look For in a New Opportunity

I'm often asked what has made us (DAI Palliative Care Group) successful  in recruiting palliative medicine physicians. There are, of course, a number of reasons. Experience is one. Our experience "informs" our recruitng efforts. We've made a study out of understanding what physicians look for. We've come to appreciate "What's Important in a Practice Opportunity to Palliative Medicine Physicians".

 

We 've learned from our experiences in HPM physician recruiting that most prospects evaluate practice opportunities through four filters. Let's refer to these filters as:

 

• Rewards (monetary) 
• Community/environment (supportive culture of teamwork and recognition of contribution by HPM physicians) 
• Workload schedule (manageable workload and sustainable schedule) 
• Autonomy/control (ability to impact key factors that affect job performance).

Of course, each physician will place his or her own value upon each of these criteria in career decision-making.  The key to recruiting physicians (particularly in a market  where demand far exceeds supply) is to create a practice opportunity that recognizes and addresses all four filters in a balanced way.

Future posts will offer more detail into each of these filters and recommendations on how to create the "balanced" HPM practice opportunity.

 

 

 

Recruiting in Markets Where Demand Exceeds Supply

From time to time, clients inquire how they might best recruit a talented palliative care specialist. I've found success by utilizing recruitment approaches that have produced results in other markets where demand for talent exceeds its supply. In such markets, the scales are tipped in favor of the professional, in this case, the palliative medicine specialist.

How to best restore a balance? By understanding how specialists in short supply make career decisions, and then using methods that can best reach those "passive" candidates. The most commonly used method - job board postings - are most effective in reaching "actively-looking" candidates, usually in markets where supply exceeds demand. Such postings will typically not work in reaching "passive" candidates, since these individuals know well that, because of their relative scarcity, securing a new position is relatively easy.

Candidates in short supply need to be "approached and asked" and then "sparked and nurtured". This process is very demanding of time on the part of the hiring company /manager, and so frequently the "inside" recruitment team will be strengthened on an adhoc basis by bringing on a recruitment specialist with insider knowledge of the particular market.

When to Add a Hospice and Palliative Medicine (HPM) Physician to your Practice

Most hospice and palliative medicine (HPM) programs and practices are experiencing growing demand for their physician services. These growing pains, obviously, can put a strain on current staff and the practice's infrastructure. A physician practice that is stretched beyond capacity because of an unfilled position cannot carry the patient and on-call load of a larger group for an extended period of time. The overtaxed and overwhelmed physicians are prime candidates to leave the practice, seeking opportunities where they can find better control over their workload. In other words, unfilled positions beget unfilled positions. That is why turnover is often referred to as the "silent killer" of a practice.


One of the most challenging tasks for a HPM medical director or practice manager is determining how many physicians are needed to staff the program. Since most HPM practices do not generate revenue greater than their compensation, knowing when to add a full-time physician is not an easy decision to make. But it is important to consider the costs and lost revenue associated with an unfilled position as well as the salary it takes to fill it. Take a hospital inpatient palliative care consult service, for example. A 2008 study by the National Palliative Care Research Center found that savings from palliative care consults for hospital inpatients ranged from $1,500 to $5,000 per admission. A palliative medicine physician who performs 40 such consults per month will produce savings of at least $60,000 per month for the hospital. Or take a hospice program with a palliative care consultation service and a physician making home visits to palliative care patients. One-third of those patients can be expected to transition to the hospice benefit, generating, on average, $1,500 in hospice revenue per patient. An HPM physician visiting 30 patients per month on the palliative service will produce $15,000 in patient service revenue for the associated hospice.

While these guidelines are handy in building a case, alone they do not make a clear case for when a physician should be added. Nor will the conceptual approach, projecting the work for a time period (e.g., 5,000 home visits/year) and dividing that projection by the amount of work performed by one FTE HPM physician (e.g., 920 home visits/year). Careful consideration of several other factors will also enhance the decision-making process: use of non-physician providers, such as nurse practitioners; variation in workload (need to staff higher than the average to address spikes in service demand); expectations around nonclinical commitments that may include administration, teaching and research; and the need for off-hours coverage, vacations and the like. The right timing in adding a physician to a HPM practice will likely accelerate success. Mistiming will stymie program (and practice) growth. In future posts we will look more closely into effective ways to attract the right candidates to your practice.

Palliative Care Grand Rounds - May 2011

Hiatus over. Welcome to the May edition of Palliative Care Grand Rounds (PCGR), a monthly (now appearing the second Wednesday of each month) summary, or mash-up, of interesting, thought-provoking, timely, relevant, humane, and exceptionally well-written postings from the blogosphere.
Several topics dominated the news, and thus the blogs, covering palliative care. Prescription opioid abuse is one, and Drew “Feeling Grumpy” Rosielle addressed this subject in his post on the blog Pallimed.

Also, on the 16th of last month bloggers united around the 2011 Blog Rally for National Healthcare Decisions Day (NHDD). Nathan Kottkamp founded NHDD back in 2008 as a nationwide advance care planning awareness initiative. Larry Beresford, accomplished hospice journalist, took up the torch in posting a personal story about completing his own advance directive. In the blog Hospice Doctor, a palliative medicine specialist muses about the decision-making process (for clinicians and family) behind the care of an 88-year woman whose death in a hospital followed 11 days there with considerable (some futile?) treatment.

Which leads me to the third subject in the April palliative care news stream. The Dartmouth Atlas of Health Care has released a new report, "Trends and Variation in End-of-Life Care for Medicare Beneficiaries with Severe Chronic Illness," documenting trends in the care of chronically ill patients in the last six months of life. This report was covered extensively in the mainstream media, less so in the blogosphere. You can check the PBS NewsHour coverage of this story in this post on its blog.
Then see the comments this blogger posted  regarding the huge and persistent variations across hospitals, communities, regions, and states. If you agree that these variations in late-life care practice appear intractable, share with us your thoughts—what do you think can be done?

GeriPal bloggers Drs. Eric Widera and Alex Smith were themselves featured in a New York Times blog post.  Together with colleague Dr. Sei Lee, they are developing a Web site that offers individual prognoses based on 18-20 different geriatric prognostic indices. When you visit the blog post, be sure to spend a few minutes reviewing the comments. Here’s a topic that apparently resonated with many readers.

And speaking of the blog GeriPal, congratulations on being chosen as the Best Clinical Weblog of 2010. In one of its April posts, it looks more closely at the results of a study on nurse practitioner models of palliative care. And Geripal blogger Alex Smith jumped over to another blog, Kevin MD, to comment on
the hospice and palliative care community’s unrelenting yet fruitless search for a simple and consistent message. Speaking about a message that benefits from consistency, and also at the blog KevinMD (its tag line is “social media’s leading physician voice”), a geriatric psychiatry fellow posts that palliative care and medical interventions are not mutually exclusive.

Many thanks to Christian Sinclair for originating Palliative Care Grand Rounds several years ago, and for sustaining it since. But to state the obvious, PCGR’s continued publication depends upon fellow bloggers…like you. Do let Christian know of your interest in adding your incisive post.

National Healthcare Decisions Day - April 16

This post is part of the 2011 Blog Rally for National Healthcare Decisions Day. If you have a blog please post it and leave it up on the front page through April 16th. -Ed.


Rallying to Encourage and Empower Us All to Make Our Healthcare Decisions Now for the Unknown Later…

College education. Career path. Relationships. Starting a family. Buying or selling a house. Vacations. Retirement. From the age that we’re old enough to understand, most of us are taught and accept that these are the markers in life that we plan for. However, there’s one key marker that’s all-too-often missing from this list: healthcare decision-making. Like planning for these other life events, planning for the time (or times) that we are unable to express our healthcare wishes is of the utmost importance. It is something that should be well thought out, documented and revisited at different points in life to reflect any change in our desires or family situation or the person we wish to advocate for us. Unfortunately, it is a planning point that that majority of us have missed. As a consequence patients’ families suffer the added burden of having to guess when a health crisis happens. That’s why Nathan Kottkamp founded National Healthcare Decisions Day (NHDD) back in 2008 and why this nationwide advance care planning awareness initiative is as important as ever. So this year, I’ve joined my fellow bloggers throughout the country to spread the word about the importance of advance care planning with this special NHDD edition blog.

NHDD, which happens every April 16, is a collaborative effort of national, state and community organizations as well as dedicated individual advocates committed to ensuring that adult Americans – like you and me —have the information and opportunity to communicate and document their healthcare decisions.

 Here are some things you can do for yourself and your loved ones to prepare for NHDD 2011:

Lead by example. Schedule time with your loved ones  to “Have the Talk” and complete your own advance directive. There are many tools, including free forms, you can use to walk you through the process and make your wishes known; access them through the NHDD Public Resources page.

Encourage your loved ones and friends to learn more about advance directives and to complete their advance directives. You can forward this link: http://www.nhdd.org/p/resources.html to them. Or, encourage them to find a nearby participant and attend a local NHDD event.

Share your advance directive with your healthcare providers and make sure it is on file in the event it is needed.

Already had the conversation with your loved ones, but want to do more? Here a few suggestions to rally support for NHDD and encourage even more action:

Like the NHDD Facebook fan page and share it with your Facebook friends

On Twitter? Follow @NHDD and share the information with your followers.
Send an email to your friends, staff, colleagues, lodge/social club members, and/or house of worship, telling them that you are participating in NHDD and encouraging them to do the same. Share the information above with them and/or use this template email:

April 16 is National Healthcare Decisions Day, and I hope that you will join me in taking this time to discuss and document your healthcare wishes. We all need to be prepared in the event of a health crisis, and having the talk is easier than most people think, but many of us need a little inspiration or a reminder to do it. I hope that this message and National Healthcare Decisions Day are all you need. Please mark your calendar for April 16 to have the talk with your loved ones. There are all sorts of free resources, including free advance directive forms for each of the 50 states, on the NHDD website: www.nhdd.org. Additionally, please help me spread the word with Twitter, Facebook, and LinkedIn. Advance care planning is something we ALL should do and encourage others to do, regardless of age or current health. Discussing your wishes can be one of the most important gifts you ever give your loved ones.

Act now and grow this rally further: use and share the resources available through the NHDD website and encourage and empower us all to make our healthcare decisions now for the unknown later.