Hospices and hospitals increasingly focus on palliative care programs

Even a free-standing hospice can make it work

Palliative care programs are growing in number and prominence at hospitals and hospices across the nation, as increasing numbers of health care providers want to focus on medicine used as much for comfort and quality of life as for diagnoses and cures when dealing with patients who have chronic illnesses for which there are no easy resolutions.

The number of hospital-based palliative care programs nearly doubled between 2000 and 2003 to 1,100, and now about 1,800 physicians have become board-certified to participate in palliative care, says Amber Jones, BA, Med, hospice liaison consultant at the Center to Advance Palliative Care (CAPC), based at Mt. Sinai School of Medicine in New York City.

There also has been an increase in the number of nurses specializing in palliative care, she adds.

There are about 200 certified advanced practice nurses now, and soon there will be more, Jones says. "There also are licensed nursing assistants in palliative care, and so we're seeing a huge growth in the number of palliative care-trained professionals," she adds. "We did a survey of hospices 2½ years ago, asking how many were interested in providing palliative care services, and 25% were already offering palliative care services and 90% were in the process of planning it."

For hospices, the move to palliative care is a natural one, says LaDonna Van Engen, RN, CHPN, hospice program coordinator of Saint Elizabeth Hospice of Saint Elizabeth Regional Medical Center in Lincoln, NE.

"In order for hospices to survive with Medicare, Medicaid, and insurance, we need to promote and look at palliative care," she says. "It offers people the control they want."

Palliative care is becoming an attractive service for patients with a wide variety of chronic diseases, including congestive heart failure, emphysema, peripheral vascular disease, and end-stage heart disease, experts say.

The concept is directed toward supportive care for patients who have symptoms that are not well controlled, medication side effects that have led to a poor quality of life, and chronically ill patients who are not terminally ill.

For instance, a person with advanced heart disease might be routinely shuffled into surgery, but the palliative care approach would have a team help the patient look at the quality-of-life risks of such surgery and make a decision that, while not ideal, may be better suited to their needs and situation, Van Engen says.

"Maybe if families knew all of the opportunities and options they might make different choices," she adds.

Van Engen says under the palliative care approach, she would say to the adult child of an 80-year-old patient whose health is failing rapidly, although no one disease qualifies as a hospice referral, "Tell me about your mom. What kind of person is she? Would she want you to do everything to keep her alive like this, and can she get better?"

"When someone is facing a serious, chronic, or life-limiting illness, they also have a lot of emotional issues, and they need to make decisions about what they want with the rest of their life," says Cindy Marsh, executive director of the Hospice of Texarkana (TX) Inc., a free-standing, community-based, nonprofit hospice that provides palliative care services.

"They may need to make advanced directives and those types of things are addressed with the social worker on the team," she says.

Likewise, the social worker will help palliative care patients understand what will happen when they're discharged from the hospital."

Palliative care education

The biggest question hospices have with regard to palliative care isn't whether to provide these services, but how, Jones says.

CAPC answers the how question by providing educational programs that help health care providers build a business plan and gain support for the utilization of palliative care services, she explains.

One program is a two-day intensive seminar that provides a primer on building a palliative care program with lectures, small group sessions, and the goal of providing attendees with an understanding of the elements of the program, Jones says.

CAPC also offers site visits at one of the organization's six palliative care leadership centers, at a cost of $1,500 to $1,750 for four people. A health care team may visit a center over a two- to three-day period to gain hands-on experience with people who have been through it, Jones explains.

The team typically brings to the site visit data from the hospice or hospital, which can be used in developing a business and implementation plan, she adds.

As a follow-up, the visiting teams receive a year of technical support from the leadership center.

The Hospice of Texarkana formed a palliative care program after staff received training from CAPC, Marsh reports.

The palliative care initiative is two-pronged: The first and main effort involves a collaboration with CHRISTUS St. Michael Health System in Texarkana, and the other effort will be the opening of an outpatient palliative care clinic at the hospice medical director's clinical setting, she says.

"We had been working with CHRISTUS for some time in providing hospice services, and we had gained their trust in both our clinical operations and in how we conduct business with our patients there in the facility," Marsh says.

The hospice's mission was helped by CHRISTUS leaders who wanted to implement palliative care services in all of the health system's facilities, she notes.

"What made this effort extremely successful is the fact that CHRISTUS contracts from us a nurse liaison who is working with case management on a daily basis to identify patients who might benefit from a palliative care consult," Marsh says.

The Hospice of Texarkana program also involves a social worker and doctorate-level pharmacy consultants, she says.

The palliative approach

Palliative care contacts with patients and families involve at least two disciplines with the goal of making it a team meeting, Marsh says.

"I think one of the real strengths of a palliative care program can be continuing the interdisciplinary approach that is so successful in hospice," she says.

For hospices that already are part of a hospital system, palliative care is a natural fit both clinically and economically.

For example, Saint Elizabeth provides some of the same comfort and support for patients and families referred to palliative care services as those referred to hospice, although the palliative care patients do not have to have a diagnosis of fewer than six months to live.

"We provide comfort care on things besides healing," says Van Engen.

Palliative care patients must meet Medicare guidelines for home care services, but they receive home care with the additional comfort and support that palliative care offer, she says.

"Medicare doesn't recognize palliative care in the home at this point," Van Engen adds.

Hospices that have home care services or are affiliated with health systems with home care services train home care staff to provide a palliative approach to their care, she explains.

"The staff don't just provide wound care, but focus on end-of-life issues, family support, and that sort of thing," Van Engen says. "With the palliative approach, the home health aide may say, ‘I'm going to give them a bath, but if they insist on not getting up today, I won't push that hard.'"

The benefit to the hospital system is that referring chronically ill patients referred to palliative care services helps to reduce rehospitalizations and saves health care dollars, both Van Engen and Marsh note.

Palliative care staff provide focused education and care for patients who have multiple symptoms and medical problems that typically result in frequent rehospitalizations, Marsh says.

"One of the things we found most helpful in aiding the hospital is identifying patients who are returning to the hospital because their symptoms are not controlled, or the support in the home is not adequate to maintain them," she says.

In discussing palliative care services with hospital administrators, the hospice used the hospital's own readmission data to highlight the cases where patients were not able to stay home for at least 30 days, Marsh adds.

It's also better medical practice because it provides a more holistic approach to making certain patients receive the appropriate level of care, Van Engen says.

"We have someone sit down with the patient and identify what the goals are and make the best decision they can," she says. "Sometimes that means the patient will say, ‘No, I don't want to have that test.'"

A registered nurse serves as a liaison member of the palliative care team, and the hospital's social workers and pastoral care staff also are on the team. A hospice pharmacist is on the team, and a hospitalist physician is the palliative care medical director, Van Engen says.

"The hospitalists have been instrumental in referring patients to the service," she reports. "We thought we'd be most requested in oncology, but we have seen patients in every unit of the hospital."

In the palliative care model used by Hospice of Texarkana, the palliative care team is made available to the attending physician for treating patients when their pain, nausea, anxiety, or other symptoms are out of control, and the hospice is reimbursed by the hospital through a palliative care contract, Marsh says.

"Although we never want to be seen as a barrier to care, what we do provide is an opportunity to have a big picture conversation," Marsh says. "If the hospital is seeing you as being a good steward with a plan of care even when in their setting and when it's their financial risk, then you have a lot of trust and credibility in place when you introduce this idea to them."

Need More Information?

  • Amber Jones, BA, Med, Hospice Liaison Consultant, Center to Advance Palliative Care, Mt. Sinai School of Medicine, New York City. Web site: www.capc.org. E-mail: abjones@nycap.rr.com.
  • Cindy Marsh, Executive Director, Hospice of Texarkana, Inc., 803 Spruce St., Texarkana, TX 75501. Telephone: (903) 794-4263.
  • LaDonna Van Engen, RN, CHPN, Hospice Program Coordinator, Saint Elizabeth Hospice, 245 South 84th St., Suite 100, Lincoln, NE 68510. Telephone: (402) 219-7043.