How can hospices maximize leverage?
Tips on joining the palliative bandwagon
If hospices cannot gain significant attention from their local health care institutions in the competence they have in caring for dying patients, they will find that hospitals will simply create a parallel structure within the institution, says John Carney, MEd, CEO of Hospice in Wichita, KS.
That means hospices will fail to serve those patients who die in the hospital, Carney adds. "If we're serious about caring for patients at the end of life, where ought we be?" he says. "I think it's our future. A good hospice of the future will have a relationship and a presence in acute care hospitals."
But how can community hospices find ways to participate in the hospital palliative care development described in this month's cover story? The movement's leaders offer the following suggestions:
1. Check your arrogance and superiority at the door.
"Hospices need to realize that people in the hospital, at least some of them, already know how to do this work," says J. Andrew Billings, MD, director of the palliative care service at Massachusetts General Hospital in Boston. "In our palliative care practice, we have very complex cases, and many patients who have rejected hospice referrals. When we do have patients for them, there is a certain kind of hubris that sets in. The fact that I was once a hospice medical director and my nurse used to run a hospice is forgotten. They should be respecting us and relying on us more," he says.
2. Build on existing linkages.
Treat the hospital as a customer and don't approach the conversation simply as an effort to persuade the hospital to make more referrals. Instead, the hospice needs to go into the hospital and ask what it can do to help the facility, says James Hallenbeck, MD, associate professor of medicine at Stanford University, Palo Alto, CA.
3. Offer education about hospice and end-of-life care.
"At several of our sites, which established new linkages, acute care folks are much more understanding of what hospice offers and much more enthusiastic about making referrals," says Connie Zuckerman, JD, director of the New York City-based United Hospital Fund's Hospital Palliative Care Initiative. But first, the hospice has to be able to come in and demonstrate its competence and value.
On the other hand, Hallenbeck observes, a single grand rounds presentation on "Hospice 101" isn't going to transform physicians' behavior. Hospices as a group have not done a good job of changing physician attitudes and behaviors. "The best time to shape physician behavior is in residency training," he says, suggesting an obvious need for hospices to contribute to that training.
4. Consolidate scattered beds into a designated palliative care unit.
"This often provides a platform for relationship building," says Paul Brenner, MDiv, coordinator of Jacob Perlow Hospice at Beth Israel Medical Center in New York City.
Hallenbeck adds that many hospices seem to underutilize the hospice acute care benefit and fail to take advantage of its opportunities for bringing difficult symptoms under control. Several community hospices could come together and jointly sponsor a palliative care unit at a major medical center, he suggests. This joint sponsorship could serve their patients' need for inpatient care better than separate, scatter-bed contracts, while providing a center for specialized palliative care expertise in the medical center, he says.
5. Recognize the proper role of the hospice medical director.
"One of the potentially limiting areas for many hospice programs is that they have not built up the medical director's role as a member of the team," says Laurel Herbst, MD, vice president and medical director at San Diego Hospice. Using a volunteer or part-time medical director limits the hospice's ability to impact acute care development, and also has implications for quality of care, she says. "If the hospice wants to work outside of the box, and doesn't have a full-time medical director or adequate physician hours, it will be much harder."
Hallenbeck also emphasizes the value of additional training for hospice medical directors, and credentialing such as certification by the American Academy of Hospice and Palliative Medicine in Reston, VA.
6. Make the venture data-driven.
"We started by doing our own version of SUPPORT [Study to Understand Programs and Preferences for Outcomes and Risks of Treatments funded by the Robert Wood Johnson Foundation of Princeton, NJ] with a retrospective chart review and interviews with families, nursing staff, and house staff, in order to get a profile of what the state of the art really was," Brenner says. Much to the hospital's surprise, it discovered serious problems, which mobilized the administration's commitment to change. "But it requires doing a needs assessment to get objective data."
7. Maintain high standards.
A commitment to service, user-friendliness, and high standards of quality, as well as the ability to quantify these achievements, will go a long way toward making the hospice an attractive partner in palliative care development.
"The best hospice programs should be the standard on which other end-of-life programs are judged," says Ira Byock, MD, program director of the Robert Wood Johnson Foundation Promoting Excellence in End-of-life Care program. "Those of us who are deeply committed to best-practice standards need to get out and lead this development. If we don't, we'll be sorry that we didn't. If we don't become the official voice of this new discussion, who will? And will they really reflect the principles of hospice?" Byock argues.
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