Next new hospice product could be palliative care consulting

Provision of medical advice can help reach nontraditional patients

Palliative care consulting is much the same as other types of consultations in health care. In general, consultation is a type of service in which one provider seeks the opinion or advice of another provider regarding evaluation or management of a specific problem.

Under Medicare Part B, physicians request the opinion of specialists to ensure accurate diagnosis and proper treatment. This does not mean patient care is transferred to the consultant. Medicare has specific rules regarding consultation between physicians, including the requirement that the request for consultation and the reason for the request be documented in the medical record. The opinion and any investigations or services ordered or performed also must be documented.

Documentation aside, the consultant examines the patient and gives advice to the provider managing the patient’s care.

Palliative care consultation services offer physicians and hospital staff the opportunity to consider end-of-life care options for their patients. Palliative care consultations normally focus on the following:

  • pain and symptom control;
  • discharge planning and continuity of care;
  • decision-making at the end of life;
  • psychosocial issues involving patients and families;
  • ethical issues.

Palliative care consultation services can take various forms, such as when the hospice medical director is the sole provider of the service. In some settings, palliative care consultation is interdisciplinary, including such team members as physicians, nurses, social workers, chaplains, or psychologists.

Hospice of the Bluegrass in Lexington, KY, operates an interdisciplinary palliative care consulting practice. According to administrator Gretchen M. Brown, the creation of a consulting team fits with the organization’s mission.

"It’s our mission to serve the terminally ill, but there are some terminally ill patients we don’t get — those in intensive care units, for example," Brown says. "When we started this, we thought it would help our length of stay and help bring in more patients."

In Hospice of the Bluegrass’ consulting practice, the hospice medical director is the consulting physician, and the hospice bills the consultation services under Medicare Part B. Palliative care consultation works like any other attending physician/consulting physician relationship. An attending physician requests the opinion and advice of the hospice medical director, who also may call upon interdisciplinary team members for input.

The hospice does not take over medical management of the patient unless the attending physician approves the transfer of care. The consulting physician does, however, provide follow-up communication to the attending physician in the form of phone calls, letters, and copies of clinical notes.

While there is reimbursement for consulting services, it is not a service line hospices should launch to increase revenue. Reimbursement for consultation is not remarkable, experts say. Instead, Brown sees the cost associated with palliative care consulting as part of the cost of doing business. Palliative care consulting is critical to the hospice’s mission to serve dying patients no matter where they are, she says.

"This is an area in which we have expertise," Brown says. "Hospitals are starting their own palliative care centers. We can provide the expertise, or we can let hospitals do it."

Know the customer

If a hospice expects palliative care consulting to generate revenue or help increase access for patients, hospice executives and staff should understand what their intended customers expect.

While each physician is different, and each community varies in its level of familiarity with palliative care, there are general areas in which physicians and hospital staff are looking for help. These include:

Advice on physical and psychological issues surrounding end-of-life care.

Typically, physicians will seek assistance in four domains:

  • pain and non-pain symptom assessment and management;
  • assistance in making difficult decisions, usually about continued use or withdrawal of technological treatments such as feeding tubes, dialysis, or ventilators;
  • assistance in planning for the most appropriate care setting and level of care to meet patient and family goals for end-of-life care;
  • providing psychological support to patients, families, and the health care team.

A clear statement of the hospice’s goals under palliative care consultation.

After a detailed discussion of the patient’s history and family support structure, requesters of palliative care consultations will expect a hospice to describe its goals for the consultation and how it fits with the goals of the physician, the patient, and his or her family. Patients and family may have concerns regarding the consultation. You should explain your goals in an easily understood fashion.

Advice or assistance in engaging the patient and family regarding the patient’s current medical condition.

Like most people, physicians are not adept at discussing the topic of dying. While they can talk about clinical matters, they often need help discussing treatment options outside the realm of curative medicine. They will expect hospice consultants to provide information and advice to patients and their families, taking into account cultural and psychosocial issues.

Patients may have a difficult time understanding why a consultation is necessary, or they may have preconceived ideas that contribute to a negative attitude toward hospice and palliative care. Physicians will need help emphasizing the positive aspects of palliative care, such as improving quality of life through pain relief, symptom control, and restoration of functional capacities.

Serving the broader community

On a larger scale, hospices can be palliative care consultants to the entire community, using the consultation team to educate the public and health care professionals. Hospices can approach specific sectors in their own community in the following ways:

Physicians: One of the hurdles hospices face in getting physicians to refer patients earlier is the perception that the physician would be letting go of the patient. Hospices need to get across the message that hospice care is still physician-directed. Perhaps physicians in a hospice provider’s community are unaware of hospice’s physician-directed interdisciplinary team approach. Hospices need to explain to physicians who have referral potential that the hospice team approach calls for the patient’s physician to take a lead role and work with the hospice medical director, nurses, social workers, counselors or chaplains, and other health care professionals.

Hospices should start with hospital medical staff meetings to educate physicians about hospice and palliative care. Another educational device is a newsletter aimed at physicians that explains the principles of hospice care, including the value of palliative care.

It’s also a good idea to stress dialogue between physicians and end-of-life care promoters, either through educational efforts, such as pain management guidelines, or a toll-free hotline. While a single hospice cannot influence the curriculum of a medical school or nursing school, it can influence the habits of the clinicians with whom its works.

Community: If the idea behind educating physicians is to increase the number of referrals, then hospices should educate the public so hospice will be considered when it becomes appropriate.

Hospices can accomplish this by visiting various groups within the community. Hospice leaders should identify community groups that would benefit from a presentation about hospice, such as nursing homes, community centers for the elderly, or local chapters of AARP.

Talk to a population that has had little exposure to death and dying: teen-agers. Religion classes in churches, synagogues, and schools are ideal platforms for end-of-life discussions.

The end result is that teen-agers share the discussion with their parents and get them thinking about end-of-life issues and how they want their parents to be treated.

No matter the group, hospice supporters should try to facilitate end-of-life discussions. For instance, audience members should be encouraged to talk about their experiences with the deaths of friends and relatives. This not only gets the audience to think about issues they haven’t considered, but it also gives providers a glimpse of the public’s impression of end-of-life care.

As people begin to contemplate end-of-life care, hospices should encourage the audience to think about advance care planning and should offer audience members assistance in developing a statement of how they want to be treated in the last few weeks of their lives.

Managed care organizations: As managed care becomes more prevalent in some markets, contracting with managed care organizations (MCOs) becomes more important. Like physicians, nurses, and the general public, MCOs need a dose of education, as well.

However, the message to MCOs will be slightly different from the one given to the two previous audiences. Hospices will want to stress their place and value in the health care continuum.

Public forums: Ask the public to share their experiences, both good and bad. Videotape this testimony and show it to health care providers to raise their awareness of problems within end-of-life care.

Pain management guidelines: Develop pain management guidelines and a curriculum on pain management to be used in medical schools and nursing programs. The curriculum should be designed to help educate a new crop of health care professionals regarding the value of palliative care.

Continuing education: Develop a continuing education program on palliative care and interdisciplinary pain management. Design this program to address working clinicians who were trained in an era when greater emphasis was placed on curative techniques.

Toll-free help line for clinicians: Establish a help line to encourage telephone consultation for clinicians who are experiencing difficulty managing their patients’ symptoms, such as nausea and pain. Give clinicians access to a palliative care specialist to answer their pain management questions.

Long-term care facility workshops: Conduct educational workshops for residents and staff at long-term care facilities. For instance, a workshop specifically for residents and their families may be helpful. The resident/family workshop can include educational programs and discussions of end-of-life issues. Residents should be exposed to advance care planning issues and be given assistance in developing a directive for the kind of care they want to receive during the final stage of life. Instruct participants and their families to follow up with their area hospice for additional information.

Community workshops: In addition to nursing home workshops, hospices can target service groups for community workshops. Like the long-term care workshops, the community workshops should facilitate an open discussion about end-of-life issues and advance care planning.

The above strategies represent elaborate, well-planned efforts to affect public opinion and behavior. If these programs are successful, it will be in large part to the concerted effort of the community of providers that contributed to their implementation.