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Trends in Hospice: Palliative Care Growth
[Editor's note: In this issue of Hospice Management Advisor, there are several stories, including the cover story, about the recent growth of palliative care programs in the hospice industry. Featured in this issue are the palliative care continuum of care provided by a Midwest-based home care and hospice organization and the palliative care hospital services offered by a smaller East Coast hospice. In the September issue, there will be an additional story about a hospice organization that has made palliative care a big part of its mission and business.]
Pioneers in hospice palliative care say trend will continue through this century
NHPCO offers a book of models for hospices
Palliative care continues to grow within health care systems and networks, and increasing numbers of hospices across North America are embracing the palliative care approach and philosophy as part of their own missions, experts say.
The number of hospices providing palliative care services has increased dramatically in the past four years, according to a recent survey by the National Hospice & Palliative Care Organization (NHPCO) of Alexandra, VA.
A membership survey conducted in 2002 found that 26 percent of hospices provided some palliative care services. The same survey, repeated in 2006, found that 55 percent of hospices provided palliative care services, says Judi Lund Person, MPH, vice president of quality for NHPCO.
Among the respondents providing palliative care services, 58 percent said they worked with hospitals or provided hospital-based palliative care, including pain management, assistance with goals of care, and family support, Person says.
Half of the respondents said they offer a palliative care consultation team to hospices or to nursing homes, she adds.
The large growth during the past four years proves that palliative care is an idea whose time has come, Person says.
"All of hospice is palliative care, but not all of palliative care is hospice," Person says. "There are patients who will accept palliative care services, but will never move over to hospice."
It's up to hospices to make sure their palliative care services are beyond the Medicare hospice benefit and are providing services to seriously ill patients who are not yet terminally ill, Person says. "We also should help palliative care become integrated into lots of different places in the health care system, including working with nursing homes, working with hospitals and intensive care units, and providing additional support to families."
Some hospice organizations have integrated palliative care into both home care and hospice services.
Palliative care is a natural direction for home care agencies and hospices to take, says Lin Pekar, RN, BA, CHPN, CLNC, director of palliative and chronic care at Heartland Home Health Care and Hospice in Toledo, OH. Heartland has 110 offices in 26 states, with most locations providing both home care and hospice services.
"If you're already in home care and receiving compassionate discussions [through palliative care services], then it's more natural to discuss hospice," Pekar says. "We try to spread the word about hospice, and through the philosophy of palliative care, we're able to do that much better."
Less than a decade ago when Heartland first adopted a palliative care philosophy, home care agencies and hospices had no true collaboration. Now organizations like Heartland are building a continuum of care that benefits patients, Pekar notes.
According to the NHPCO survey, many hospices already have moved into the direction of providing non-Medicare palliative care services.
"The number of [NHPCO survey] respondents in 2006 was 350, and 55 percent of them said they were providing palliative care outside the confines of the Medicare hospice benefit," Person says.
Nearly three-fourths of these hospices were providing non-hospice palliative care programs, and this was especially true of hospices with a daily census of 100 patients or more, Person says.
"For programs that served an average daily census of between one and 25 patients, 46 percent of them were saying they offered palliative care," Person notes. "You might say small providers couldn't do this, but they were offering palliative care."
One of the smaller hospices that NHPCO identifies as a pioneer in the area of palliative care is the Coastal Hospice in Salisbury, MD. The hospice's average daily census is 85 patients, including inpatients, says Marion F. Keenan, MA, MBA, president of Coastal Hospice.
The hospice's board decided to pursue palliative care about two years ago, she says.
Keenan and other leaders at the hospice attended palliative care sessions at an NHPCO conference, gathering information before they submitted a recommendation to the hospice's board that the organization further pursue palliative care, Keenan recalls.
The result is a partnership with Peninsula Regional Medical Center in Salisbury. Coastal Hospice provides a physician, nurse practitioner, and some social work and pastoral care to palliative care patients in the hospital in exchange for a stipend from the hospital to cover some of the costs, Keenan explains.
"We've had increasing numbers of palliative care referrals," Keenan says. "About 43 percent of the palliative care patients eventually become hospice patients."
While there are some business benefits to providing palliative care, the hospice didn't expand its services in this direction to make money, Keenan says.
"We lose some money on it, and we justify that loss by saying it seems so right for our mission," Keenan says. "We were a hospice before there was ever any reimbursement and before there was a six-month prognosis, so it doesn't seem strange to us."
The hospices surveyed by NHPCO reported they were offering palliative care services to meet an unmet need, to fulfill their mission, and to position their hospice as a leader in the palliative care continuum in the community, Person adds.
The barriers they reported included the lack of reimbursement for services, the perception that physicians didn't place a high value on palliative care services, and the lack of understanding and experience in billing, Person says.
At the Hospice and Palliative Care of Charlotte Region in Charlotte, NC, it was a physician's vision that instigated the hospice's move to palliative care services.
The hospice's medical director had a vision about providing quality end-of-life care for both hospice patients and patients who still wanted to receive aggressive therapy, says Judith Kinsella, RN, MSN, CHPN, assistant vice president of medical services for Hospice and Palliative Care of Charlotte Region, which has an average daily census of 450 patients.
The visionary medical director saw a gap in care between the excellent symptom management received by hospice patients and the less optimal care received by chronically ill people who did not meet the hospice diagnosis criteria, Kinsella says.
With leadership and drive at the top for palliative care, the hospice started an extensive palliative care program that has grown within a few years to having nine full- and part-time physicians, plus six nurse practitioners, a disease management coordinator, a social worker, two nurses, two administrative assistants, and a nurse manager, Kinsella says.
The palliative care average daily census is 330 patients, she says.
The hospice has contracted with Charlotte's flagship health care system called Carolina Healthcare System, which pays for some of their palliative care services, Kinsella adds.
"We don't give anything away for free because we can't," Kinsella says. "So what we do is billable visits from practitioners, and all palliative care for the hospital is paid from contracts."
The move into palliative care has been a huge benefit to the hospice organization, Kinsella notes.
"It's ramped up people's view of hospice care overall," she says.
Quality palliative care helps spread the message about quality end-of-life care, Kinsella says.
"We hire people well-skilled in communication, as well as clinical care aspects, and it speaks well for our hospice organization overall," she adds.
Hospice leaders who wish to start palliative care programs, or expand their existing services, could learn more about the pioneers of palliative care from a 200-250-page monograph/book, titled, "Navigating Palliative Care: Positioning Hospice for the 21st Century," that is expected to be published by NHPCO this summer, Person says.
"We're jointly doing a monograph with the Center to Advance Palliative Care (CAPC)," Person says.
NHPCO published a similar monograph in 2001, but the new one provides cutting edge information, she notes.
NHPCO conducted site visits of hospice providers who were doing exceptional work in expanding palliative care, focusing on legal, regulatory, business planning, and the future of palliative care, Person says.
Among the sites visited were Coastal Hospice, a Heartland Home Health Care and Hospice site, and the Hospice & Palliative Care Charlotte Region.
"We made sure we featured providers who had a reputation of having been out there doing palliative care very early compared to other providers," Person says.
The featured hospices are geographically diverse and represent urban and rural, big and small, free-standing and hospital-based hospices.
"Our goal is that providers who read the monograph can take the experiences of these pioneers featured through in-site visits and apply what they've read to expand their own programs in their own areas," Person says.
Chapters will include site visit reports, lessons learned, getting started, developing a business plan, staffing, finance and billing, legal and regulatory considerations, opportunities across settings, quality control, and veteran's administration organizations, Person says.
"There are lots of resources and links to Web sites and forms for people to take and modify so they won't have to re-invent the wheel," Person explains. "It's a way to help providers jump in and think about how they can partner and do palliative care on their own in their own community — that's the goal."
Palliative care programs and services are absolutely essential to the future of hospices, Pekar says.
"When you look at the demographics of the chronically ill, you see that we're an aging society," Pekar explains.
"Predictions are that by 2020, we're talking about 157 million Americans living with one or more chronic illnesses, and half will have two or more chronic illnesses," she says. "We need to find a more successful model to improve their outcomes and meet the needs of the chronically ill, and I think palliative care is going to be that innovative strategy to help us get better at disease management."
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