Trends in Hospice: Palliative Care Growth

[Editor's note: In this issue of Hospice Management Advisor, we've included the second part of a series about the recent growth of palliative care programs in the hospice industry. Featured in this issue is a story about how one hospice organization has made palliative care a big part of its mission and business. In the August issue, there were articles about 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.]

The Hospice and Palliative Care of Charlotte Region in Charlotte, NC, is one of the largest hospices in North Carolina and a national leader among hospices that have incorporated palliative care into their mission.

The organization even changed its name from Hospice of Charlotte to a name that includes palliative care several years after shifting its focus to include palliative care.

"We cover all medical services for hospice and palliative care, and we have seven physicians who are dedicated toward the palliative care side," says Judith Kinsella, RN, MSN, CHPN, assistant vice president of medical services. The hospice has a daily census of 450 patients.

"We hand-picked and carefully selected physicians to work in our practice," Kinsella says.

Among the physicians who work in palliative care are a pulmonary specialist and a neurosurgeon, she notes.

By employing physicians and nurse practitioners to work in palliative care, the hospice has reaped some benefits. About 35 percent of the patients in the palliative program, which began in 2003, eventually transition to hospice care, and the hospice's census have increased from about 250 in 2002 to about 450 in 2006, Kinsella says.

"In 2006, we saw 1,982 new consults," she notes. "It's pretty significant."

Also, the palliative care patients who are transitioned to hospice care tend to be less expensive to the hospice than typical hospice patient because these patients have already received assistants with establishing goals of therapy, Kinsella says.

Here is how the comprehensive palliative care program works:

  • Employ a productivity model: "We built a productivity model," Kinsella says. "We have a budget and billable visits that we want to achieve every month to cover our costs."

Each palliative care practitioner is given a budgeted number of visits to reach each month, and their actual visits are tracked electronically, Kinsella says.

"We have a ratio of what we want to see of how many patients per FTE [full-time equivalent] each month," Kinsella explains. "We look at this to see if we're on target."

It's a detailed process that includes sending practitioners quarterly reports telling them how many visits they've made for the quarter and year-to-date, she adds.

The organization also has hired a medical billing specialist who makes sure providers are in compliance with Medicare Part B billing requirements, Kinsella says.

"We submit bills to her, and she makes sure they're the right code," Kinsella says. "She reads the notes to make sure we're maximizing our utilization of the code appropriately."

All of these measures have helped keep productivity high.

"We've been constantly amazed," Kinsella says. "They all have salary positions, but they're highly motivated to see patients, and they've been consistently meeting their productivity goals."

Palliative care services include patient visits at home and in long-term care facilities, and in March, the organization opened outpatient clinics, Kinsella says.

Some of the billable visits involve nurse practitioners in the long term care setting, Kinsella says.

"It's never going to be 100 percent covered, but the benefit burden is significant," she says.

Nurse practitioners are paid through the Medicare Part B billable visit. When palliative care patients are transitioned to hospice care, they'll receive the Medicare A benefit and the nurse practitioners will no longer see them, Kinsella notes.

"We see patients in 25 nursing homes, and we have about 60 home patients," Kinsella says. "We've had up to 120 home patients, and once we opened the outpatient clinic, many palliative care patients transitioned there."

There are detailed reports that are used to look at average monthly expenses, and administrators continually analyze the palliative care budget, Kinsella says.

  • Expand physically and organizationally to accommodate new services:

Hospice and Palliative Care of Charlotte Region has contracted with the flagship health care system in the region to provide palliative care services, and this arrangement helps to cover some salary costs, Kinsella says.

The hospice organization expanded its office space to accommodate palliative services.

"We have a whole floor for medical services, and each doctor and nurse practitioner has his or her own desk and space," Kinsella says.

Palliative care nurses, doctors, administrative staff, and a social worker meet each Friday to discuss case studies, Kinsella says.

Administrative assistants manage the organization's database and keep track of the staff's CMEs, disability administrative work, and scheduling.

"The scheduler helps physicians and nurses schedule their palliative care visits," Kinsella says.

Whether a site has one palliative care patient or 10 patients, the clinicians will go to see them, but the organization works to create greater density in the hospitals and nursing homes visited by staff, Kinsella says.

"Having a large number of patients in a nursing home is wonderful," she says. "Having one or two is difficult."

  • Educate, market, assist other health care professionals: When the hospice first began the palliative care program and began the contract with the major health care system, hospice leaders held many inservices and discussions with the health care system's hospital and nursing home staff, Kinsella recalls.

"Nursing homes like having us there," Kinsella says. "They love having a physician come in and see patients and help them establish goals of therapy and refocus the care of patients."

The organization has a journal club that meets monthly for PowerPoint presentations about palliative care and end-of-life issues, Kinsella says.

Physicians and nurse practitioners read current literature and create the two-hour presentation which is presented to peers and other professionals, including nursing and medical students, she says.

"They're highly motivated to make sure the literature review has been complete," Kinsella notes.

Sometimes the topics selected are part of a theme chosen for the year.

"This year we decided we wanted to spend journal club time on a dementia series, so each topic is related to dementia," Kinsella says.

Among hospice and palliative care populations, the diagnosis of dementia is increasing, she notes.

The presentations are saved in a medical service library so they can be accessed later by anyone who missed the original presentation.

Also, the staff can receive CMEs for listening to the PowerPoint presentations, and the person who develops the program receives CME, as well, Kinsella says.

The program's reputation initially was enhanced by the advocacy of the hospice's medical director, who is well known in the community. But it has also grown by virtue of its own success.

"We love to look back at where we've been," Kinsella says. "It speaks loudly about our senior leadership who are strong advocates of what we've been doing, and that's key."

Also, the partner hospitals believe palliative care is an important service to add, so it helps the program thrive and grow, she says.

"We continue to look at maintaining our growth by adding new hospitals, new nursing homes, and new service areas," Kinsella says. "We have to do that to maintain as a palliative medicine program."

Need More Information?

  • Judith Kinsella, RN, MSN, CHPN, Assistant Vice President of Medical Services, Hospice and Palliative Care of Charlotte Region, 1420 East Seventh Street, Charlotte, NC 28204. Telephone: (704) 375-0100. Email:; Web site: