Hospice Trends

Interest in palliative care creates growth opportunity

Inpatient consults a tough market

By Larry Beresford

The growth of palliative care and the development of palliative medicine consultation services are major end-of-life trends with huge implications for America’s hospice industry. Proponents say palliative care consultations offer hospice agencies a vehicle for sharing their expertise in pain and symptom management or life-transition counseling and end-of-life care planning in new contexts with seriously ill, hospitalized patients who are not yet ready or eligible for hospice care.

A hospice palliative care consultation service can be developed as a new program or product line or even as a clinic or a physician practice incorporated by the hospice agency, which bills Medicare and other payers for reimbursable physician consultation visits provided by its employed medical director and interdisciplinary team. Potentially, this service could encourage earlier consideration of hospice care by patients, leading to earlier and more appropriate hospice referrals, reducing the incidence of very-short-stay hospice patients, while helping the hospital better manage its most difficult, costly patients.

But some observers question whether it is realistic for most community hospices to send a palliative care consultation team into the high-technology, highly politicized acute care environment and expect them to prosper — let alone to be taken seriously by hospital staff and physicians. Hospice professionals obviously possess end-of-life skills needed by seriously ill patients, but do they have all of the tools and knowledge — and confidence — they will need to function within the acute care setting? Do they have an activist medical director and other team members who can command credibility, speak the language, and understand the culture of the hospital? Or will they be viewed as fish out of water, enmeshed in cultural clashes that condemn the new service to failure?

On the other hand, it’s clearly not impossible, because a number of leading hospices are already offering inpatient palliative care consultations under varied auspices and models of collaboration with hospitals. These services generally have not yet succeeded in generating a profit on billing income alone, although they are justified on the basis of collateral benefits.

The National Hospice and Palliative Care Organization (NHPCO) in Alexandria, VA, has proposed a new benefit called hospice palliative care consultation, which would provide Medicare coverage at customary physician billing rates for a new range of consulting services provided by the certified hospice’s interdisciplinary team to patients not enrolled in hospice care. A more limited version of this proposal, covering a one-time hospice "educational visit" by the hospice medical director, made it into the Medicare legislative package recently passed by the U.S. House of Representatives.

Meanwhile, the conferences, publications, and other resources of the Center to Advance Palliative Care (CAPC) — including a sponsored workshop at the upcoming NHPCO Management and Leadership Conference Sept. 6 in Phoenix and a December 2001 monograph titled Hospital-Hospice Partnerships in Palliative Care: Creating a Continuum of Service — have continued to promote a collaborative model of inpatient palliative care development by hospitals and hospices.

But the question remains: Is palliative care a viable direction, service, and new product line for the majority of America’s hospices? Can they attract the consultation referrals they will need to make this product line succeed? If so, how can they maximize their chances of success in expanding access to appropriate end-of-life services and thus reach more patients with end-of-life needs earlier in the disease progression? The answers to these questions will help to shape the future of America’s 3,200 hospices.

New things to learn

Hospice nurses possess considerable skill and experience in end-of-life care, but when they enter the inpatient realm, they may encounter treatment modalities and other issues that are unfamiliar, especially given the rapid pace of change in hospital medicine, observes J. Andrew Billings, MD, a one-time hospice medical director who now heads the palliative care service at Massachusetts General Hospital in Boston. "I have seen this issue with people on my own staff. There are things they need to learn to provide good care for patients in the hospital, even if they already have a solid background in hospice and palliative care," he says.

"We already have experience from hospice’s involvement in nursing homes and the lessons that were learned there. For instance, it is not easy to become part of another institution and its culture. Also, it is important not to come in acting as if you know all of the answers. You don’t want to seem arrogant. You need to be willing to listen and learn," Billings says.

Some hospice and palliative care services have targeted the intensive care unit (ICU) as a setting where end-of-life perspectives and consultations could be especially helpful (see HMA, March 2003, p. 31), but Billings warns that the ICU setting, in particular, requires an intimate understanding of contemporary medical techniques and technologies. Without obvious ICU experience and expertise, it will be hard for the palliative care team to garner much credibility.

The questions that are raised about hospice’s ability to provide a successful palliative care service in the hospital may reflect more familiarity with the "old" Medicare-model hospice than with the degree of diversification now being practiced by some leading-edge hospices, notes Gretchen Brown, president of Hospice of the Bluegrass in Lexington, KY. "We are living proof that it is possible for a hospice to successfully operate palliative care services," says Brown. Hospice of the Bluegrass operates palliative care services at Lexington’s three acute-care hospitals.

On the other hand, Brown wonders whether most American hospices really want to diversify and make the programmatic changes necessary to succeed in palliative care. Step one is to invest in a competent, respected, full-time medical director (see HMA, July 2003, p. 81).

Hospice-run palliative care teams also should be familiar with the palliative applications of chemotherapy and high-tech treatments when those are appropriate and desired for the patient. Is the hospice willing to tackle the difficult cases and the ambivalence many patients and families experience before they are ready to consider hospice enrollment? "Do you have the ability and willingness to look forward and take risks — to consider the upside, downside, and unintended consequences of an initiative such as this?" Brown asks.

Find a champion on the inside

"If you are serious about it, then you need to identify your champion inside," she says. "How are you going to get the data you need — which belong to the hospital?" Without the results of a comprehensive needs assessment, the hospital might not appreciate the level of unmet need in the institution, and the hospice won’t know where to target its efforts at patients in need, Brown says. "If some doctors are already referring to your hospice for pain consults, that’s a clue that you have friends inside," she notes. "On the other hand, it would be a mistake to go in and just say, Here we are.’ That won’t work."

It’s not a sound business strategy to craft a new product like palliative care without significant involvement by the intended customer in planning and needs assessment, Brown says. You need to make sure the customer buys into the product.

Hospice of the Bluegrass’ hospital palliative care teams are jointly staffed, with team members assigned and funded by both the hospice and each hospital, building on considerable groundwork in terms of joint needs assessments, planning, medical advisory committee involvement, and other relationship-building efforts.

Hospice of the Bluegrass is the sole hospice provider in many of the communities it serves, thanks to a state certificate of need and a long and constructive relationship with local medical communities. The hospice’s medical director, Terry Gutgsell, MD, who is well-known and respected within that community, also did a one-year palliative medicine fellowship at the Cleveland Clinic before taking his current position.

Know thyself

"The fact that hospice’s role in palliative care within the walls of the hospital is open to question illustrates the problem: a lack of openness by some hospitals to collaborate in responding to the shortcomings of inpatient end-of-life care documented by the SUPPORT study," observes Bill Finn, president of Hospice Buffalo (NY) and the Center for Hospice and Palliative Care in Cheektowaga, NY. As the next wave of managed care focuses on disease management approaches to coordinating the care of complex, expensive patients, palliative care for patients nearing the end of life would seem to be an obvious opportunity for improving coordination and continuity of care, he says.

The Buffalo hospice operates a palliative consultation service at Buffalo General Hospital and its affiliated hospitals, building on historical relationships with its medical director, Robert Milch, MD. Finn says palliative care is an appropriate way to expand access for a hospice that can see above the horizon. "The good hospice already knows what’s going on inside the hospital, has relationships with its community’s hospital providers, and understands its own strengths and weaknesses," he says.

For hospices interested in exploring palliative care development, the first commandment is to "know thyself," Finn says. "Next, benchmark. Take a look at the best programs you can find and see which ones fit your program and mission." There is a range of options open to hospices in working with hospitals, and they need to be explored. "The calling is there; it’s really a matter of doing good due diligence," Finn notes. "Also, bear in mind that very few programs are generating net revenues on these services. On the other hand, we’re not talking about a huge commitment of money. Starting small is not a bad idea."

Hospices need to be persistent in developing the labor-intensive relationships that lead to collaborative palliative care services, Milch adds. "You demonstrate the validity of the service you’re offering by providing a good product. Then people will come to your door. That’s how hospice grew in the first place."

Integrated end-of-life care

Even if NHPCO succeeds in obtaining legislative support for hospice palliative care consultations, the ultimate success of these services depends on integrating them into a broader continuum of end-of-life care. If the hospice is able to admit patients directly onto the Medicare hospice benefit while they are still in the hospital; if it can respond to referrals and consultation requests within hours instead of days; if it can establish a visible presence in the hospital through a dedicated hospice inpatient unit, these advances will help to fix the hospice in the minds of other health care professionals as the solution to difficult end-of-life cases.

If the hospice can involve the hospital in a collaborative team approach, then both sides will be invested in the program’s success. It’s important to build the hospice medical director’s profile in the medical community — by serving on physician committees, for instance — and to establish close working relationships with hospitalists practicing in the community’s hospitals.

Hospice remains the gold standard and most intensive form of palliative care, but the experiments now going on with palliative care consultation services remind us that patients have many end-of-life care needs before they are eligible or able to consent to hospice care. The more the hospice can be involved in finding solutions to those other needs, the more assured will be the place for its full hospice benefit services within the integrated continuum of end- of-life care.

[Editor’s note: Health care journalist Larry Beresford of Oakland, CA, was primary author of the CAPC monograph, Hospital-Hospice Partnerships in Palliative Care: Creating a Continuum of Services. Contact him at (510) 536-3048 or at larryberesford@hotmail.com.]