Community-Based Palliative Care Steps Into Population Health Spotlight
It is well-known that patients in their last year of life account for approximately 13% of total annual US health care spending. But did you know that the costliest 5% of patients account for 60% of health care costs? And 90% of the costliest 5% are not in the last year of life? Simply put, the “sickest of the sick” in our communities, who are not generally eligible for hospice services, would be prime beneficiaries of a community-based palliative care program. In an era of value-based and risk-sharing delivery models, such a program would provide significant benefit, both to the chronically ill population by filling a gap in their care and to health systems by creating cost savings through care coordination and reduced utilization.
Many believe that the real “payoff,” both clinical and financial, will be when community-based palliative care becomes an established part of the health care continuum. In fact, organizations such as Kaiser-Permanente and Aetna have developed community-based, nonhospice palliative care programs and report both increased patient satisfaction and annual cost savings of over 20% compared with matched controls.
Although hospice services are reimbursed by CMS on both a home-based and inpatient basis, reimbursement for palliative care is unpredictable, depending on your market and payer landscape. Despite this, an increasing number of institutions are implementing palliative care programs because of the potential cost savings. The combination of aggressive symptom management, ongoing discussion of treatment goals and preferences, and care coordination reliably leads to effective, efficient care with reduced high-cost health care utilization, such as ED visits, hospital admissions and ICU length of stay. Savings typically range from $2,000 to $8,000 annually for patients receiving palliative care in combination with traditional health care.
A palliative care specialist often leads the effort to build a community-based program that includes a variety of practitioners. Educational programs that articulate to primary care physicians and other providers the advantages of a palliative care approach are critical as there are simply not enough palliative care specialists to meet the needs of an aging population.
Community-based palliative care offers several advantages—the most prominent being its team approach to care that allows for scalability. Although specialty-level physician involvement is important, care coordination and treatment goal support are usually accomplished by an interdisciplinary team that may include advanced practice nurses, social workers, pharmacists, occupational and physical therapists, clergy, and volunteers.
Critical elements for community-based palliative care program success include:
- Identification of appropriate patients. Although the majority of care is provided to senior citizens, treating all seniors is neither possible nor necessary. An easy and systematic method is needed to identify individuals who may benefit. One option is to ask primary care physicians: “Would it surprise you if your patient died in the next 1 to 2 years?” If the answer is “no,” then that patient would qualify as a candidate for palliative care. Other actuarial tools that include the patient’s age and number of comorbid illnesses have been developed to identify a subset of patients who would most benefit.
- Early, aggressive symptom control. Commonly, physicians will treat a patient’s underlying disease and assume that as disease treatment progresses, symptoms will resolve. However, a palliative care approach will include disease treatment but will also focus efforts to bring symptoms such as pain and breathlessness under control rapidly. It is the symptoms that often bring a patient to an ED or hospital admission; therefore, rapid resolution of symptoms will ultimately cut costs and increase quality of life.
- Goal setting with the patient and family. This is the patient-centric aspect of care that is all too often forgotten in the course of disease treatment. Do we really know what the patient and his or her family desire in terms of quality of life, hopes and aspirations, and treatment preferences and expectations? Physicians are trained in the art and science of disease diagnosis and treatment. To be sure, many physicians aspire to understanding their patients’ needs and desires. However, it is a considerable investment to appreciate the spiritual, emotional and intellectual aspects of their patients in addition to their physical well-being. Furthermore, a patient’s goals and desires are likely to change with time and circumstance. Accordingly, a team that is connected to the patient is more likely to appreciate a patient’s goals than a physician who may only interact with that patient sporadically.
- Introduction and integration of hospice at the appropriate time. Although hospice care has grown substantially in the US, the average length of stay for hospice care has not budged in recent years. This finding suggests that, for many patients, hospice services are not engaged until the last few days of life and the full benefit of hospice is not being realized. A strong community-based palliative care program lays the foundation so that, when appropriate, hospice can be introduced and provided to allow maximal benefit to patients and their families.
As hospice has become a critical component of end-of-life care in the US, we expect that community-based palliative care will take on an even larger role in population health management, especially as our population ages and as more people suffer multiple chronic illnesses. Community-based palliative care will achieve greater prominence as the clinical benefit and cost savings become apparent to value-based, risk-sharing organizations.
Does your organization provide community-based palliative care? Want to learn more about how to start or improve your program? Contact Sg2 to learn how we can help.