Inpatient palliative care is the next frontier for hospices
Collaboration must displace territorial attitudes regarding palliative care
Despite hospices’ best efforts to reach those who would benefit from their end-of-life care, the fact of the matter is most terminally ill people either never receive hospice care or are admitted too late. Many of those underserved patients die in hospitals without the benefit of pain management and spiritual or emotional care.
For years, hospices have conceded that hospitals are a difficult referral source to tap. Patients either weren’t aware of hospice care or clung to the hope that curative efforts would win out despite the bleakest of prognoses. Then, as the debate over end-of-life care began to heat up, some hospitals have begun to realize that their patients would benefit from palliative care, making their foray into a domain once exclusive to hospices.
As this trend continues, how should hospices react to this movement? Should it be one of disdain for hospitals that have paid little attention to the palliative care needs of their patients in the past? Or should hospices embrace their health care counterparts’ newfound enthusiasm for principles hospices have championed for years?
According to Larry Beresford, a senior writer for the Alexandria, VA-based National Hospice and Palliative Care Organization (NHPCO) who has been on special assignment studying hospice and hospital palliative care collaborations, hospice administrators should see the development of inpatient palliative care programs as an opportunity to collaborate with their hospital colleagues.
The NHPCO and the New York City-based Center to Advance Palliative Care (CAPC) have charged Beresford, a former editor of Hospice Management Advisor, with the task of developing a monograph for that examines hospice-hospital collaborations in inpatient palliative care. The monograph is due out sometime this year.
In Birmingham, AL, the Birmingham-Area Hospice has been an enthusiastic supporter of the Balm of Gilead, an inpatient palliative care center inside the city’s Cooper Green Hospital.
"Cooper Green was a main referral source to our hospice," says Gregory Townsend, program director for the Birmingham-Area Hospice, which is run by the Jefferson County Health Department. "But we weren’t capturing all the patients who could benefit from our care. The Balm of Gilead helped create a seamless network between the hospital, hospice, nursing home, and health department."
Hospice input can be essential in the development of a hospital program, while patient exposure to hospital palliative care can provide patients with timely and proper information about hospice care that could facilitate more appropriate hospice admissions.
It was Birmingham-Area Hospice Medical Director Frank Amos Bailey, MD, who championed the idea of bringing palliative care to patients admitted to Cooper Green Hospital and helped the hospital secure a three-year, $500,000 grant from the Robert Wood Johnson Foundation.
"Every palliative care program needs a physician champion," says Edwina Taylor, CRNP, palliative care specialist with the Balm of Gilead.
Hospices can help hospitals establish palliative care programs that emphasize the following attributes:
• physical, psychological, social, and spiritual support to help the patient and family adapt to the anticipated decline associated with advanced, progressive, incurable disease;
• incorporation of the full array of interinstitutional and community resources (hospitals, home care, hospice, long-term care, adult day services) and promotion of a seamless transition between institutions/settings and services;
• an environment that supports innovation, research, education, and dissemination of best practices and models of care.
While hospices bring a wealth of palliative care expertise, they need to cooperate with their hospital partners as they go through the process of establishing an inpatient palliative care program. To provide direction to hospitals and hospices, CAPC has outlined this step-by-step approach:
• Identify institutional leaders and initiate
a strategic planning process. Strong, effective leadership is unquestionably the key ingredient for successful development of palliative care programs. Identify key stakeholders and champions among hospital/health system staff and from the community.
• Conduct an institutional and community needs assessment for palliative care services. Developing a new clinical service requires an organized process, convincing data, and demonstration of a compelling unmet patient need within the institution as well as the community. Begin this analysis by interviewing potential stakeholders. Assess their interests and needs. Elicit their support and identify opportunities
for collaboration.
• Survey the community for competitive palliative care services. Evaluate the following characteristics: length of time in operation; reputation and ability to meet patient needs; gaps in existing palliative care services; potential collaborative opportunities.
Provide data on unmet needs
• Profile hospital patient population and demonstrate an unmet patient need. Profile the patient population that will benefit most from palliative care. For example, demonstrate the costs to the hospital for failing to institute appropriate services and discharge options for vulnerable, seriously ill patients, many of whom are dying. Graphically illustrate the scale of unmet patient need with data such as:
— total number of hospital deaths annually by age group and insurance status;
— causes of death by Medicare DRG;
— locations of deaths (eg, medical/surgical unit, ED, ICU, etc.);
— length of stay in hospital and in ICU by DRG among patients who die in the hospital;
— discharge information (destination);
— number of patients with advance directive, health care proxy, and/or DNR order.
• Conduct focus groups. Further define your patient population and its needs by convening several small focus groups to reveal additional reasons for instituting a palliative care program. Focus groups to convene include physicians; nurses, social workers, pharmacists, and chaplains; patients in specific diagnostic groups; and family and caregivers.
• Develop a mission statement, goals, and objectives for the palliative care program. With your research completed, develop a compelling mission statement and goals and objectives that reflect and reinforce unmet need. Establish short-term (12 months) and long-term (three years) program goals that are as specific and measurable as possible. Goals to consider include:
— patient/caregiver satisfaction;
— physician and staff satisfaction;
— growth in patient volume;
— financial performance;
— impact on length of stay in hospital and ICU;
— innovation/research;
— awards/recognition.
• Decide on the range of services to offer. The range of palliative care services offered will depend on variables such as:
— gaps in existing community services;
— type of population to be cared for (e.g., complex tertiary-care referral populations vs. small community hospital populations of mostly elderly and chronically ill);
— location in the hospital where most patients die;
— inpatient hospital bed constraints.
• Select a delivery model.
• Determine funding sources. Medicare and Medicaid are the primary payers for palliative and hospice care. Medicare is the benchmark for rates paid by private insurers for these services.
• Develop a public relations and communications plan. Identify both internal and external audiences to promote the new service. Activities may include:
— program brochure and direct mail campaign;
— educational programs for referring physicians, families, and patients;
— local news and human interest stories;
— public relations and fundraising events.
• Develop an operations plan. Identify all the resources/costs required to put the program into operation, including:
— administration and management team;
— community advisory group;
— staffing;
— space renovation and rent;
— capacity (number of beds/patients per staff unit);
— medical and office equipment and supplies;
— medical records;
— quality assurance;
— public relations/communications.
• Develop a financial plan. Using cost estimates from the operations plan, develop a financial plan including a three-year proposed program budget of revenues and expenses. Project estimated revenues from all funding sources based on anticipated patient utilization and service volumes.
• Recruit a skilled interdisciplinary team. Once your program is approved, it is important
to recruit a skilled interdisciplinary team from the outset. For a dedicated inpatient unit, the team should include a physician, a nurse, a social worker, and/or a bereavement or pastoral care counselor. If having a dedicated bereavement staff is not possible, the palliative care service should be able to refer families to affiliated bereavement program staff. Other experts who can make a significant contribution to the team include patient advocates, chaplains, pharmacists, pain experts, rehabilitation experts, and psychiatric consultants.
• Develop a patient database to measure quality and outcomes. Clinical data, patient and family assessments, and financial information should be collected in easily accessible and usable databases. It is also important to track and evaluate all program research and educational activities. Data such as these help quantify the importance of the program and are critical to demonstrating the program’s benefit to the hospital’s mission and reputation.
Side effect: Timely admissions
How hospitals and hospices work together can vary, says Beresford. Work arrangements should be dictated by local needs rather than adopting a cookie-cutter approach.
In most cases, however, hospices may act simply as consultants to hospital palliative care programs, providing education and training to hospital staff to help them recognize candidates for the hospital’s palliative care programs.
The Balm of Gilead is a 10-bed dedicated inpatient unit where palliative care beds are clustered in a specific area of Cooper Green Hospital. This allows the hospital to concentrate patients with similar needs in one place where palliative care and consultative services can be provided. Supporters of this approach say a dedicated unit provides visibility and promotes acceptance of palliative care as an essential patient care service by hospital staff. As part of the program, a team composed of doctors and nurses, typically with a social worker and/or a bereavement counselor, sees patients with palliative care needs.
The Balm of Gilead has contracts with a total of seven hospices in the Birmingham area in which the hospices provide palliative care services and use four inpatient hospice beds. As Taylor describes it, the non-territorial approach of both hospital and hospices has paid off since the Balm of Gilead was launched in 1998. The program has served more than 700 patients.
Rather than those patients receiving palliative care until their death, patients who would have died in the hospital actually thrived under care delivered at the Balm of Gilead. "Less than half of the patients here actually die on the unit," says Taylor.
That meant more patients were coming home and were in need of care. The increased awareness of hospice care as a result of inpatient palliative care increased the number of hospice admissions. The Birmingham-Area Hospice went from an average daily census of 25 patients in 1998 to 63 patients today, says Townsend.
"We have been able to meet the needs of patients not quite ready for hospice care and have been able to get them into hospice care when they were ready," Townsend says.
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