There are few certainties in healthcare, but one is that hospitals will generally be facing an increasingly older population. And with age comes more chronically and severely ill patients.
According to statistics from the federal government, the number of people in the United States who will be older than 85 by 2030 is expected to double to 8.5 million. To complicate matters for hospitals, most of those older, critically ill patients will be in hospitals, as nearly all Medicare beneficiaries spend at least some time in a hospital during their last year of life. In fact, about 27 percent of Medicare dollars are spent on patients in their last year of life, and roughly 25 percent to 32 percent of patients die in hospitals.
This is a large responsibility for today's hospitals and health systems and will be an even bigger issue in the future. Diane Meier, MD, director of the Center to Advance Palliative Care, the national authority on palliative care programs in U.S. hospitals, says hospital executives need to recognize that only 5 percent of their patients drive 50 percent of all spending. Many within this highly concentrated group of people need some type of care management, and within that, palliative care could play a huge role.
"As we move away from fee-for-service and toward capitation, global budget and population management strategies, the business model requires management of that 5 percent," Dr. Meier says. "If you can't manage that 5 percent, you will go under financially. They drive so much of the spending and are such big users of the healthcare system."
Palliative care is still a relatively new movement, considering the long history of healthcare. Jim Risser, MD, medical director and head of palliative care at St. Paul, Minn.-based Regions Hospital, says the specialty has really galvanized in the past five to 10 years, and the actual definition of palliative care revolves around the comforts and desires of the patient.
More specifically, he says palliative care is a service carried out by a multidisciplinary team to help patients who have advanced, though not necessarily imminently terminal, illnesses such as cancer, congestive heart failure and Alzheimer's disease. A hospital with a palliative care program gives those types of patients various patient- and family-centered options to help cope with the serious illness, and usually there is a major emphasis on pain management, advanced care planning and the patient's quality of life. The palliative care team is made up of its core members — physicians, nurse practitioners, social workers and chaplains — and incorporates other disciplines like pharmacy, nutrition, ethics, hospice and complementary care as deemed necessary.
Dr. Risser has been at Regions Hospital, part of HealthPartners, for several years, and in October 2011, Regions became one of the first hospitals to have its palliative care program certified by The Joint Commission. He has seen his hospital's program grow over the past eight years, and he says it's vital to not confuse palliative care with hospice care.
"We continue to challenge these notions that our patients are dealing with end-of-life issues in the immediate future," Dr. Risser says. "That situation is more consistent with a hospice-type of care. I think a lot of times we get lumped into the hospice movement — and we share a lot of the philosophies, such as spending a lot of time with the patient and making them more comfortable — but palliative care is farther upstream than hospice. With palliative care, if you want to pursue more aggressive medical procedures, let's sit down and describe the benefits and burdens."
In addition, he says it is a misconception that palliative care teams are "agenda-driven" or try to limit care to people. "From personal experience, that is just not what we do," Dr. Risser says.
A typical day for the Regions Hospital palliative care team involves morning rounds on the patient census. The team goes through their patients and discusses each patient's needs — medical, social, spiritual. From there, the team will go see patients as a group (if time permits, individually if not) to get a sense of what care should be coordinated and what the patient and family want.
Joe Contreras, MD, chairman of the Pain & Palliative Medicine Institute at Hackensack (N.J.) University Medical Center, agrees with Dr. Risser. Dr. Contreras helped HackensackUMC become the first Joint Commission-certified palliative care program in New Jersey in January, and he says palliative care in hospitals is not synonymous with hospice, nor is it a care-limiting panel. Further, palliative care is not just about dissecting the situation of a disease or illness. It's about providing quality care and symptom management along with all other treatment measures, whether aggressive or comfort-based.
"It is important to understand palliative care is very different from other subspecialties of medicine. It is person-based and not disease- or organ-system-based," Dr. Contreras says. "It's a new paradigm for hospitals because we [palliative care specialists] are of the mind-body-spirit approach. We are not being asked to remove an organ or consult because the kidney is not functioning well. We're being called in because we are trying to improve an ill person's quality of life and address their suffering."
First, many patients who had suffered severe and chronic illnesses had looked for alternative ways to treat their pain and better manage symptoms and daily care needs at home, but hospitals and health systems have not always offered an alternative. Instead, hospitals may have focused their efforts on what they can do immediately in the acute-care setting.
As mentioned earlier, Medicare and healthcare costs rise significantly for those who are older and for those who suffer severe and chronic illnesses in the acute-care environment, and that is another major reason why palliative care has grown. Dr. Meier believes palliative care has caught on at hospitals and health systems because there is "so much excess spending on the acute-care side."
In fact, Dr. Meier and CAPC officials say patient-centric palliative care — through improving quality of care and person-driven care — can actually save hospitals and the healthcare system money in the long run due to shorter length of stay or lower costs per day. For example, in a given hospital with 20,000 to 30,000 admissions per year, roughly 2 percent end in death. Dr. Meier says if roughly four or five times that number are complex cases that are vulnerable to readmission, roughly 8 to 10 percent of patients may have palliative care needs and can be more effectively treated in a more appropriate setting.
Dr. Meier adds that as CMS' Value-Based Purchasing program continues to emphasize quality metrics and patient satisfaction measures, palliative care becomes a natural offshoot.
However, Dr. Contreras of HackensackUMC says hospitals that invest in palliative care programs today must keep the specialty's goal in mind: to put patients' wants and needs first and to guide them through comfortable care coordination. The result could lead to improved clinical outcomes, the easing of burdens on staff, increased retention, increased peace of mind for patients and their families, and finally, improved resource utilization.
"When starting palliative care, you make the argument that you're improving patient satisfaction, improving quality of care, improving bedside care and then discuss, by the way, there might better resource allocation as well," Dr. Contreras says.
Overall, the number of hospitals with palliative care programs has risen rapidly over the years. The Joint Commission's Advanced Certification Program for Palliative Care, which Dr. Risser and Dr. Contreras have gone through at both of their hospitals, started in September 2011 and is growing.
Dr. Meier says the number of hospitals that have recorded the presence of a palliative care team has more than tripled over 10 years. In 2000, roughly 500 hospitals had a palliative care program, and in 2011, that number ballooned to more than 1,900. Palliative care programs also tend to be more common in larger, tertiary care hospitals, whereas smaller rural hospitals and some safety-net facilities are late adopters, Dr. Meier says.
Identify a palliative care champion. Dr. Contreras says every hospital-based palliative care program needs a leader who has experience in understanding how a multidisciplinary palliative care program functions.
Dr. Risser adds that at Regions Hospital, hospitalists were the largest champions of palliative care, and they led the charge to become a "transdisciplinary" team, as well as multidisciplinary.
"Transdisciplinary is the fact that any given practitioner does not stay entirely within the bounds of his or her title, and there is a sharing of responsibility," Dr. Risser says. "Physicians may end up doing some spiritual triage, and chaplains may sit in on care coordination. That is really part and parcel of a high-functioning team: sharing responsibility of getting the story of the patient and getting a care plan that makes sense for that person."
Assemble a committee and team to educate stakeholders. After a hospital is able to identify a palliative care leader or leaders, it must put together a committee to identify the appropriate stakeholders, Dr. Contreras says. Educating these stakeholders, leadership, patients and the community at large about what palliative care services provide is essential to get a program off the ground.
"Education is a big part of this," Dr. Contreras says. "Palliative care is a service that works in concert with integrated patient care at any level, in harmony with what the patient wants and what the doctor believes the treatment plan should be. It's about respecting the values of patients and guiding them through what can be a very daunting process."
Expand palliative care to home settings. When hospitals are able to craft their palliative care programs within their walls, they must be able to reach out to their patients who can be more effectively and safely care for at home, Dr. Meier says. Instead of a patient calling for 911 or asking a relative to take them to the hospital, the hospital or health system should dispatch a palliative care team member to the home. Palliative care will eventually expand to become a home-based model, Dr. Meier says, and hospitals that practice patient-centered medical homes and accountable care organizations are on the right track.
"Transition planning recognizes the needs of patients, families and the community. We need to improve capacity and flow and make beds available for people who really need to be in the hospital, like those who need a bone marrow transplant or an operation," Dr. Meier says. "The home is much better for most patients with multiple and complex conditions or any serious illness, who are usually more vulnerable, older people. Hospitals are the worst places for them because it increases the risks of hospital-acquired infection, mortality and other adverse-outcome measures."
Focus on quality and certification. The Joint Commission and CAPC have become the main organizations to provide hospitals guidance on their palliative care endeavors. When it comes to establishing the right palliative care quality, Dr. Meier says NationalConsensusProject.org, a project of all major U.S. palliative care organizations, serves as a platform for hospitals to reach standardized quality guidelines, which is the next step for the movement.
"The next 10 years have to be about quality and standardization of guidelines," Dr. Meier says. "Just like you have a stroke program, you have to meet quality guidelines. We need to improve penetration and quality in the next 10 years, and we have to bring doctors on board."
According to statistics from the federal government, the number of people in the United States who will be older than 85 by 2030 is expected to double to 8.5 million. To complicate matters for hospitals, most of those older, critically ill patients will be in hospitals, as nearly all Medicare beneficiaries spend at least some time in a hospital during their last year of life. In fact, about 27 percent of Medicare dollars are spent on patients in their last year of life, and roughly 25 percent to 32 percent of patients die in hospitals.
This is a large responsibility for today's hospitals and health systems and will be an even bigger issue in the future. Diane Meier, MD, director of the Center to Advance Palliative Care, the national authority on palliative care programs in U.S. hospitals, says hospital executives need to recognize that only 5 percent of their patients drive 50 percent of all spending. Many within this highly concentrated group of people need some type of care management, and within that, palliative care could play a huge role.
"As we move away from fee-for-service and toward capitation, global budget and population management strategies, the business model requires management of that 5 percent," Dr. Meier says. "If you can't manage that 5 percent, you will go under financially. They drive so much of the spending and are such big users of the healthcare system."
Palliative care — what it is and is not
More specifically, he says palliative care is a service carried out by a multidisciplinary team to help patients who have advanced, though not necessarily imminently terminal, illnesses such as cancer, congestive heart failure and Alzheimer's disease. A hospital with a palliative care program gives those types of patients various patient- and family-centered options to help cope with the serious illness, and usually there is a major emphasis on pain management, advanced care planning and the patient's quality of life. The palliative care team is made up of its core members — physicians, nurse practitioners, social workers and chaplains — and incorporates other disciplines like pharmacy, nutrition, ethics, hospice and complementary care as deemed necessary.
Dr. Risser has been at Regions Hospital, part of HealthPartners, for several years, and in October 2011, Regions became one of the first hospitals to have its palliative care program certified by The Joint Commission. He has seen his hospital's program grow over the past eight years, and he says it's vital to not confuse palliative care with hospice care.
"We continue to challenge these notions that our patients are dealing with end-of-life issues in the immediate future," Dr. Risser says. "That situation is more consistent with a hospice-type of care. I think a lot of times we get lumped into the hospice movement — and we share a lot of the philosophies, such as spending a lot of time with the patient and making them more comfortable — but palliative care is farther upstream than hospice. With palliative care, if you want to pursue more aggressive medical procedures, let's sit down and describe the benefits and burdens."
In addition, he says it is a misconception that palliative care teams are "agenda-driven" or try to limit care to people. "From personal experience, that is just not what we do," Dr. Risser says.
A typical day for the Regions Hospital palliative care team involves morning rounds on the patient census. The team goes through their patients and discusses each patient's needs — medical, social, spiritual. From there, the team will go see patients as a group (if time permits, individually if not) to get a sense of what care should be coordinated and what the patient and family want.
Joe Contreras, MD, chairman of the Pain & Palliative Medicine Institute at Hackensack (N.J.) University Medical Center, agrees with Dr. Risser. Dr. Contreras helped HackensackUMC become the first Joint Commission-certified palliative care program in New Jersey in January, and he says palliative care in hospitals is not synonymous with hospice, nor is it a care-limiting panel. Further, palliative care is not just about dissecting the situation of a disease or illness. It's about providing quality care and symptom management along with all other treatment measures, whether aggressive or comfort-based.
"It is important to understand palliative care is very different from other subspecialties of medicine. It is person-based and not disease- or organ-system-based," Dr. Contreras says. "It's a new paradigm for hospitals because we [palliative care specialists] are of the mind-body-spirit approach. We are not being asked to remove an organ or consult because the kidney is not functioning well. We're being called in because we are trying to improve an ill person's quality of life and address their suffering."The case for palliative care
Dr. Meier has led the Center to Advance Palliative Care since the late 1990s, when it started as a program of the Robert Wood Johnson Foundation. Dr. Meier, who also founded (and until 2011) served as director of the Hertzberg Palliative Care Institute at The Mount Sinai Hospital in New York City, says palliative care has gained traction in the hospital arena for a couple reasons.First, many patients who had suffered severe and chronic illnesses had looked for alternative ways to treat their pain and better manage symptoms and daily care needs at home, but hospitals and health systems have not always offered an alternative. Instead, hospitals may have focused their efforts on what they can do immediately in the acute-care setting.
As mentioned earlier, Medicare and healthcare costs rise significantly for those who are older and for those who suffer severe and chronic illnesses in the acute-care environment, and that is another major reason why palliative care has grown. Dr. Meier believes palliative care has caught on at hospitals and health systems because there is "so much excess spending on the acute-care side."
In fact, Dr. Meier and CAPC officials say patient-centric palliative care — through improving quality of care and person-driven care — can actually save hospitals and the healthcare system money in the long run due to shorter length of stay or lower costs per day. For example, in a given hospital with 20,000 to 30,000 admissions per year, roughly 2 percent end in death. Dr. Meier says if roughly four or five times that number are complex cases that are vulnerable to readmission, roughly 8 to 10 percent of patients may have palliative care needs and can be more effectively treated in a more appropriate setting.
Dr. Meier adds that as CMS' Value-Based Purchasing program continues to emphasize quality metrics and patient satisfaction measures, palliative care becomes a natural offshoot.
However, Dr. Contreras of HackensackUMC says hospitals that invest in palliative care programs today must keep the specialty's goal in mind: to put patients' wants and needs first and to guide them through comfortable care coordination. The result could lead to improved clinical outcomes, the easing of burdens on staff, increased retention, increased peace of mind for patients and their families, and finally, improved resource utilization.
"When starting palliative care, you make the argument that you're improving patient satisfaction, improving quality of care, improving bedside care and then discuss, by the way, there might better resource allocation as well," Dr. Contreras says.
Overall, the number of hospitals with palliative care programs has risen rapidly over the years. The Joint Commission's Advanced Certification Program for Palliative Care, which Dr. Risser and Dr. Contreras have gone through at both of their hospitals, started in September 2011 and is growing.
Dr. Meier says the number of hospitals that have recorded the presence of a palliative care team has more than tripled over 10 years. In 2000, roughly 500 hospitals had a palliative care program, and in 2011, that number ballooned to more than 1,900. Palliative care programs also tend to be more common in larger, tertiary care hospitals, whereas smaller rural hospitals and some safety-net facilities are late adopters, Dr. Meier says.How to formulate the right program
Because palliative care is still growing as a patient specialty — and involves several challenges — building the right program takes a lot of continuous effort and attention. Here are four basic steps any hospital leader must consider before the organization starts a palliative care program.Identify a palliative care champion. Dr. Contreras says every hospital-based palliative care program needs a leader who has experience in understanding how a multidisciplinary palliative care program functions.
Dr. Risser adds that at Regions Hospital, hospitalists were the largest champions of palliative care, and they led the charge to become a "transdisciplinary" team, as well as multidisciplinary.
"Transdisciplinary is the fact that any given practitioner does not stay entirely within the bounds of his or her title, and there is a sharing of responsibility," Dr. Risser says. "Physicians may end up doing some spiritual triage, and chaplains may sit in on care coordination. That is really part and parcel of a high-functioning team: sharing responsibility of getting the story of the patient and getting a care plan that makes sense for that person."
Assemble a committee and team to educate stakeholders. After a hospital is able to identify a palliative care leader or leaders, it must put together a committee to identify the appropriate stakeholders, Dr. Contreras says. Educating these stakeholders, leadership, patients and the community at large about what palliative care services provide is essential to get a program off the ground.
"Education is a big part of this," Dr. Contreras says. "Palliative care is a service that works in concert with integrated patient care at any level, in harmony with what the patient wants and what the doctor believes the treatment plan should be. It's about respecting the values of patients and guiding them through what can be a very daunting process."
Expand palliative care to home settings. When hospitals are able to craft their palliative care programs within their walls, they must be able to reach out to their patients who can be more effectively and safely care for at home, Dr. Meier says. Instead of a patient calling for 911 or asking a relative to take them to the hospital, the hospital or health system should dispatch a palliative care team member to the home. Palliative care will eventually expand to become a home-based model, Dr. Meier says, and hospitals that practice patient-centered medical homes and accountable care organizations are on the right track.
"Transition planning recognizes the needs of patients, families and the community. We need to improve capacity and flow and make beds available for people who really need to be in the hospital, like those who need a bone marrow transplant or an operation," Dr. Meier says. "The home is much better for most patients with multiple and complex conditions or any serious illness, who are usually more vulnerable, older people. Hospitals are the worst places for them because it increases the risks of hospital-acquired infection, mortality and other adverse-outcome measures."
Focus on quality and certification. The Joint Commission and CAPC have become the main organizations to provide hospitals guidance on their palliative care endeavors. When it comes to establishing the right palliative care quality, Dr. Meier says NationalConsensusProject.org, a project of all major U.S. palliative care organizations, serves as a platform for hospitals to reach standardized quality guidelines, which is the next step for the movement.
"The next 10 years have to be about quality and standardization of guidelines," Dr. Meier says. "Just like you have a stroke program, you have to meet quality guidelines. We need to improve penetration and quality in the next 10 years, and we have to bring doctors on board."
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