HOSPICE PROVIDER PERSPECTIVES ON PROVIDING UPSTREAM PALLIATIVE CARE: FACILITATORS, BARRIERS, AND POLICY PRESCRIPTIONS
TAMAR KLAIMAN, PHD, MPH; JENNA STECKEL, MSW; CALEB HEARN, MPH; AMAYA DIANA, MPA; WILLIAM FERRELL, MPH; RAVI PARIKH, MD, MPP
UNIVERSITY OF PENNSYLVANIA
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EXECUTIVE SUMMARY
Among seriously ill patients, early palliative care is associated with improved quality of life, reduced symptom burden, and may lead to earlier and smoother transitions to hospice. However, less than half of patients with serious illness receive a specialty palliative care consultation before death. Given that most hospice providers are trained in specialty palliative care, hospice clinicians providing upstream palliative care may provide seriously ill patients access to palliative care prior to hospice referral. We conducted a qualitative study among 23 palliative care and hospice administrators and providers to learn how they envision palliative care provision, their views on the relationship between hospice and palliative care, their barriers and how they address them, and their perspectives on eligibility. This was a multi-site study utilizing semi-structured interviews. We preferentially sampled from member hospices of the Medicare Value-Based Insurance Design (VBID) Model. As such, administrators and providers were in multiple geographic areas and included 16 women and seven men. All interviews were transcribed and subsequently analyzed by researchers trained in qualitative methods. Most hospices surveyed offered palliative care services upstream of hospice. Respondents noted benefits of early access to palliative care, which included psychosocial support, and grief and bereavement support for loved ones. Additionally, providing community-based palliative care via hospice clinicians was noted to address access barriers to clinic- or hospital-based services and improve transitions to hospice. Barriers to upstream palliative care included staffing challenges that impeded palliative care access and reimbursement challenges for early palliative care services. Upstream palliative care is both a meaningful service, and oftentimes acts as the “bridge” to hospice. Payers can facilitate uptake by broadening and specifying coverage of services to include goals of care conversations and symptom management among others. Automatic referrals triggered by objective measures can potentially increase access to upstream palliative care. Respondents expressed a desire for more guidance from payers in identifying eligible patients for palliative care; however, they were cautious about external third party agencies acting as direct service providers. Payers could facilitate uptake by broadening and specifying coverage of services including goals of care conversations and symptom management. Automatic referrals triggered by objective measures could potentially increase access..
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BACKGROUND
Palliative and hospice care are both medical specialties offering patients interdisciplinary layers of symptomatic, psychological, and administrative support separate from curative treatment; but they are distinct in their services, eligibility, and reimbursement models. Hospice and palliative care both have demonstrated benefits including reduced costs for payers and families.1,2 Hospice enrollment is associated with improvements in end-of-life care, symptom relief, and adherence to patient goals,3 while palliative care has been shown to improve quality of life, symptom burden, and outcomes in patients with serious illness, and reduce hospital admissions.4–6 However, both palliative and hospice services are severely underutilized.7,8 Insurance coverage for specialty palliative care services varies widely - with some services being covered under a standard benefit plan (i.e. palliative care consultations, family counseling), while others are not (i.e. home safety assessment, spiritual professional, etc.).9 Previously documented barriers to palliative care referral include patient and provider unfamiliarity, provider reluctance to initiate conversations about palliative care referral with patients and their families, and lack of access to high-quality specialty palliative care.10–16 Additionally, there are several barriers to hospice care referral relating to benefit design. Hospice care eligibility, determined by the Centers for Medicare and Medicaid Services (CMS), usually requires an anticipated life expectancy of six months or less; most hospice agencies require forgoing most diseasedirected therapyWith rare exceptions, health payers follow this criteria for setting their own commercial hospice benefit. Clinicians are often uncertain about declaring a definitive six month prognosis, with 63% of clinicians being overoptimistic.17,18 Hospice organizations’ own eligibility policies result in varying rates of hospice eligibility. One survey-based study found the 78% of surveyed hospices reported at least one restriction in their policies, such as denying service to patients receiving chemotherapy or requiring patients to live with a caretaker.2 Crafting a successful upstream palliative care program demands working within the nuances of the policy, reimbursement, and societal landscapes of palliative and hospice care. We conducted a qualitative study among 23 palliative care and hospice administrators and providers to learn how they navigate these waters. We learned how they envision palliative care provision, their views on the relationship between hospice and palliative care, their barriers and how they address them, and their perspectives on eligibility.
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METHODS This was a multi-site qualitative study utilizing semi-structured interviews. The goal of these interviews was to understand barriers to palliative care delivery in current practice, as well as appropriate eligibility and intervention components for palliative care. We specifically included hospice care providers and asked them to give their perspectives on how upstream palliative care could lead to earlier hospice referrals for appropriate patients. The research team at Penn (Dr. Klaiman, Dr. Parikh, Mr. Ferrell) developed a draft interview guide, and collaborated with the funder (Humana) to finalize the guide. The interview guide (see Palliative HEAVY Interview Script) targeted clinicians who treated patients with advanced illness and included questions focused on upstream palliative care services and their potential impact on hospice services and care. We were specifically interested in learning about the implementation of hospice services and potential lessons learned for implementation of upstream palliative care services.
SAMPLE AND RECRUITMENT A professional contact of the Principal Investigator (R.P.) provided the research team with contact information for CEOs of member hospices of the MA Medicare Advantage Value-Based Insurance Design (VBID) Model. The research team conducted additional outreach to members of the Principal Investigator (RP)’s professional contacts. We used snowball sampling to recruit clinical and administrative employees from hospice care organizations. Participants were approached via email.
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DATA COLLECTION AND ANALYSIS Interviews were conducted by phone by a Clinical Research Coordinator trained as an MSW and in qualitative methods (J.S.) between March and August 2022. All interviews were recorded. Interviews took approximately 30 minutes to one hour to complete. Participants were offered a $150 gift card for their participation. There were no relationships established between the researcher and participants, and the researcher did not provide personal background or report personal characteristics. The researcher used a semi-structured interview guide, which she pilot tested with two participants. No repeat interviews were carried out. Verbal consent was obtained from each clinician who participated in the semi-structured interviews. (See Palliative HEAVY Interview Script for the template for verbal consent.) Written consent was not necessary for this project because clinicians were not required to participate and could opt out at any point. No patient identifying information was provided to clinicians. Interviews were conducted until thematic saturation was reached. No participants had access to the transcripts. All interviews were professionally transcribed and the interviewer wrote field notes about each interview. In addition to interview questions, we collected basic demographic information including respondents’ age, race, gender, practice type, market, and number of years in practice. Data were entered into Atlas.ti version 22.1.5.0. A codebook was developed that included a priori themes as well as themes that emerged from the interview data. All interviews were coded by at least two research staff members (TK, CH, JS). The focus of this project was to capture perspectives that could help design an effective palliative care intervention program. The researchers did not conduct consensus coding during the coding process, as disagreements were welcome to ensure multiple perspectives were captured. Once all data were coded, theme sheets were developed to review each of the identified themes and corresponding data. All researchers reviewed the theme sheets and came to consensus on exemplary quotes that reflect the identified themes Participants did not provide feedback.
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RESULTS All twenty-three individuals we contacted agreed to participate. Respondents included 16 women and seven men. Twenty-one respondents were white, on was Black, and one preferred not to answer. Additional demographic information is noted in Table 1 and 2. Twenty-one respondents represented organizations that offer palliative care services in addition to hospice services. One respondent’s organization previously offered palliative care services and one was from an organization whose sister organization offered palliative care services. Twenty-two respondents worked for a not-for-profit organization whereas one worked for a forprofit organization.
Table 1: Participant Roles
Table 2: Participant Geographic Representation
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BENEFITS OF UPSTREAM PALLIATIVE CARE
All respondents were supportive of patients having earlier access to palliative care to meet the needs of seriously ill patients. Benefits of early access to palliative care include goals of care discussions, psychosocial support, education, nutrition, occupational therapy, symptom management, care coordination, spiritual services, durable medical equipment services, physical therapy, transportation, and grief and bereavement support for loved ones.
So one is that they are likely to have a better quality of life because they are likely to have
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better symptom management. And they may not have to go to the hospital so much because they may not have as many pain crises or dyspnea crises or vomiting crises, so that’s one
part. And the other is that they’re likely to have their goals of care addressed when they’re still able to participate and able to think about it over the long term and kind of adjust what their hopes are for their treatment as their illness progresses over time, as opposed to waiting until it’s too late and they can’t have an impact. (001) Being able to order that, especially if you have someone who has COPD, right? Being able to provide the oxygen and things of that nature, maybe the long reach for them to get in and out of the shower and chairs and things of that nature, to make their life a little bit more comfortable. (002) [Palliative care should include] the full complement of art, music, pet therapy, guided imagery, the other expressive therapies. (017)
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COMMUNITY BASED PALLIATIVE CARE Many respondents provide services to patients in a variety of settings, including clinics, assisted living facilities, and inpatient units. This variety addresses respondents’ value that the setting should be determined by the patient’s needs and abilities. All respondents discussed the benefits of community based palliative care in which patients are seen in a community setting such as their residence, as opposed to inpatient settings. Most respondents mentioned increased quality of life, better symptom management, increased access to care, and/or reduced healthcare spending as impacts of community-based palliative care.
"
I believe that impact of community-based palliative care is actually bringing the resources to
the patient, no matter where they reside. We actually can improve equity and access to care
for those particularly with severe illness, serious illness or advanced chronic illness that have challenges being able to get to – (009) …it enhances the ability to provide holistic palliative care. I’m not saying that you can’t receive good palliative care in an office setting, but I think you can’t get the whole picture unless you’ve been into their home and see how the – what their other – what their living environment is like. I think, as far as social determinants of health, you’re not gonna get the
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true picture unless you understand their environment that they live in. (022)
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Community-based palliative care visits can also help address obstacles for patients getting to clinics including frailty from advanced illness states and lack of transportation access.
The primary population we serve are frail, elderly, homebound patients who are homebound because they either have significant frailty and functional limitations, physical limitations, or because they have significant cognitive decline. So, Alzheimer’s, dementia, those sorts of
things. But we also have a population of younger, disabled individuals in that program who are also home-limited because of their physical disability. And then we also serve a population of frail but younger Medicaid and dually eligible individuals who just have enormous complexity of – medical complexity, social determinants of health complexity. So, these are individuals who actually can get out of their house and go to the doctor in a brickand-mortar setting, but they really do much better with a team coming to their home setting. So, those are the three populations we serve in our home-based primary care program. (006)
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The patients who have a hard time leaving their home are great for community-based palliative care, patients who have many, many appointments that they already are seeing providers for, those two. (013)
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IMPROVED TRANSITION TO HOSPICE In addition to the benefits of palliative care in and of itself, access to palliative care often allows for a seamless transition to hospice. The transition is facilitated by the relationships formed with the palliative care team, and the trust engendered in that relationship.
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What sometimes happens, and maybe even often, is that if people are engaged in a palliative care encounter, it may make them more likely to think of comfort care as a viable option.And it may make them more likely to engage hospice services when the time is right as opposed to aggressive interventions which may not – which are, you know, potentially more burdensome than beneficial. (001) It has a large impact in our area.Like I said, we have a 50 percent conversion rate of patients that come into our hospice program from palliative care.So, we receive a lot of palliative care – well, we call palliative care flips, meaning they come over to hospice (020)
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BARRIERS TO UPSTREAM PALLIATIVE CARE Despite the benefits of upstream palliative care, respondents discussed a variety of barriers that impede patients’ access to these beneficial services.
STAFFING CHALLENGES IMPEDE ACCESS TO PALLIATIVE CARE Many respondents reported widespread staffing shortages in the industry, particularly since the Covid- 19
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pandemic – another challenge in providing hospice and palliative care.
There’s a nursing shortage everywhere right now… And then I just think, given what’s going on nationally with workforce shortages, it’s – if we have somebody retire, which we’re anticipating happening next year, it may be really difficult to replace them. (006) Because palliative medicine is a specialty. And trying to find providers that have the heart and the passion to do what we do.There’s a limited taskforces already for healthcare providers, and Covid definitely impacted that. So, finding the right person for the right job can be a challenge. (010)
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Respondents sometimes lacked the resources to employ the types of team members they wish they could or provide the number of patient visits they would like. Respondents wished they could hire licensed supervisors, chaplains, social workers, and staff who address social determinants of health.
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…a person that has the role that crosses over between healthcare, healthcare advocate and social worker, [a community health practitioner] is going to be really important… To be a
community resource advocate, so someone that can actually do the linkages to community services, someone that isn't limited by a social work degree or a nursing degree that can cross the boundaries, the interdisciplinary boundaries. So be kind of a go-to advocate for
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everything the patient needs. (017)
Respondents emphasized staff training and certification, with some saying it is difficult to find sufficient employees with the proper training.
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REIMBURSEMENT CHALLENGES IMPEDE PROVISION OF PALLIATIVE CARE While payers define and reimburse eligible hospice services, palliative care services may not be covered by insurance. Some care providers must provide part of their services unreimbursed because the Medicare benefits do not cover the quantity or quality of each service that they wish to offer. Some organizations employ development teams to seek out philanthropic funding to increase access to services that are not reimbursed by Medicare.
Most of the dietician services end up not being reimbursable. Chaplain services are not reimbursable. The RN and nursing support isn’t reimbursable. We will send an RN to the home to follow up and that’s not reimbursable. Let’s see, what else? Occasionally, the
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occupational therapy isn’t reimbursed, because the particular patient may have utilized all of their skilled nursing skill days in different ways, but we would still provide occupational therapy if it’s appropriately needed for their palliative care diagnosis. (013) Some of [the cost of providing palliative care] is offset. Very little bit of it is offset by any grants we get. And then the rest is supported by our organization who has a commitment to that – to non-hospice palliative care as part of their mission. (022) We have a philanthropy team that seeks out funding, whether it’s from private donors, grant sources. (008)
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Some organizations partner with or refer to other organizations for services like at-home care, but often these services require patients to have extensive resources as they are private-pay.
The home healthcare would be coming from a home healthcare agency. Sometimes the patients will go home with home healthcare after hospitalization and that usually lasts for about two months. And some of the family members are finding that that additional help
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was exactly what they needed, so they’ll go ahead and pursue either with that company that they’re currently working with or myself as a medical social worker. I can try and link them with a home healthcare agency to be able to keep their loved one at home and provide the support that they need. (023)
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We have a separate LLC formed, legally around that program. So, the non-medical homecare is really – some of our staff that render that care are CNAs, others are caregivers. And so, it is truly all non-medical, such as light housekeeping, running errands, companionship, some light AVLs in grooming – very light – meal prep. So, it’s all designed around non-medical. What we’re finding is that, especially through the pandemic, is people want more and more to be able to age at home. And so, people have resources, because that program is a complete private-pay program. And so, if the patient and/or the family have resources to pay for the program, they can be in receipt of it. But unfortunately, if they don’t have the resources, they’re not eligible to receive the services. So, we set it up as a sustainable model. (005)
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Although there are clear benefits to providing palliative care upstream of hospice, there are policy barriers that inhibit the implementation of palliative care services including lack of reimbursement or standardized quality metrics.
THE ROLE OF PAYERS Respondents viewed payers as influential in setting palliative care eligibility and quality standards, and they expressed a desire for payers to be more engaged in the identification of palliative eligible patients and communication of palliative eligibility to patients.
[payers are] starting to realize that quality of life for the individual, along with costcontainment for them as an organization, palliative care is one of their solutions. Many of
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them are developing their own palliative programs. Many of them are developing their own hospice programs...Take care of the patients proactively further upstream, is gonna give a much higher quality of life, gonna give better clinical and psychosocial outcomes, and it’s gonna reduce cost. Again, it comes back to the triple aim. (005) ...they play an important role for us in being able to recognize who of their members are eligible for the service and helping to make that connection in a meaningful way. (009)
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PERSPECTIVES AROUND FOR-PROFIT OR THIRD-PARTY INVOLVEMENT IN PALLIATIVE CARE Respondents were skeptical of the growing trend of third-party or for-profit entities serving as direct providers of palliative care, most commonly citing conflicts of interest and profit motives.
I think when [third-parties] try to be providers, and it’s a whole different world and a different mindset, and I think that leads to self-referral, and it’s just not so good. (003)
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I think that gets a bit dicey, as it relates to just some conflict of interest and some competitive nature that starts to come about when the [third-parties] are organizing and trying to penetrate into the market.That would seem to me to be disruptive and could deconstruct a lot of other meaningful partnerships. It creates a more unhealthy competitive structure. (009) So it’s concerning when you have [for-profit entities] who are also clinicians and I can’t get past how there’s not some conflict in those two areas.We absolutely see as a non-profit provider when we look at statistics nationally when you cut quality into three categories, programs that are non-profit, for-profit and then programs that are backed by equity investors, quality drops when you go from non-profit to for-profit and then it drops again when you go to equity investor backed.And so when profit becomes the primary motive of care, sometimes those outcomes are concerning and we see that in the non-profit sector when we compare ourselves and the data. (018)
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FACILITATORS TO UPSTREAM PALLIATIVE CARE STAFF TRAINING Some companies are addressing this by providing their own training to staff and implementing trainings within local hospitals.
We’re working on a lot of retention strategies now. It’s a mindset. All of our advanced practice nurses and physicians are board certified, so that kind of slims the pool down a little bit because it’s not really emphasized in medical school. So we are doing fellowships
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with our local hospitals to train people in palliative care and hospice so that they have a better understanding of it when they graduate, and then I think that’s one of the ways that we’re trying to bolster the whole understanding of what palliative care and hospice is about but also to kind of feed our need for physicians and stuff and advanced practice nurses. (004) Well, so we – I mean, I think the biggest sort of challenge for us in the beginning was NP recruitment. So the work – for us, the biggest part of our workforce is nurse practitioners. I mean, we have social workers and nurses but they are not the ones that are making the visits. It’s the NPs that are making the visits. Or if we add a health coach. But they’re primary the main service that is providing the in-home visit. So it was nurse practitioner recruitment but we do our own internal education. So education and professional development also reports to me. So we have our own recruitment, we do our own education curriculum, we’re looking at an NP residency program potentially in the future, those kinds of things. But the typical recruitment challenges related to shortages. (019)
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POLICY CHANGES TO FACILITATE REIMBURSEMENT FOR PALLIATIVE CARE Many respondents want to have a standardized definition of palliative care the way hospice does, to codify treatment and enable greater reimbursement.
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They could actually cover things.Yeah. Hospice is fairly well spelled out in terms of what’s covered.It’s fairly uniform. Most of the patients that receive hospice care are Medicare
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recipients. So it does change a bit if people have private insurance or Medicaid. But not a lot, it’s usually fairly similar. And the Medicare coverage requirements are spelled out in federal
statutes. They do get reinterpreted over time. So it is something that changes a bit based on the current interpretation of what we’re supposed to be paying for for what they’re paying us. But it is fairly clear what should and shouldn’t be provided by the hospice in terms of coverage. (001) I think everyone’s hoping that eventually there’ll be a Medicare benefit that covers it… Sort of the – you know, the way you described, like that it would be available for patients regardless of their life expectancy. Right? So the life expectancy part wouldn’t be included there as criteria for entry into the program. (016)
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TELEHEALTH Respondents suggested telehealth in addition to, or instead of, home visits as a reimbursable alternative that addresses some of the challenges of patients having to leave their home by allowing them to have appointments remotely.
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The other piece tied to that, though, is reimbursement. If the government and other third-
party pairs going to allow for that. So, definitely caring for a patient in their home, whether it be an assisted living facility, in their own home, their condo, their apartment, and with a video platform to supplement, is absolutely ideal. (005) And we have patients that have family members all over the country and we can get them on a telehealth visit, they would never be able to do that to come to our office. So that’s a terrific thing… (012)
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INCREASING PATIENT REFERRALS TO UPSTREAM PALLIATIVE CARE Clinicians who are treating the presenting illness may be the first to discuss palliative care with patients, and they are often responsible for orienting patients and families to palliative care.
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When we have an inpatient team or a clinic-based team that’s talking to a patient about us, those folks, they are almost always admitted to our program. Oncologists, a lot of oncologists will talk to their patients about our program and they’re gonna help. And the social workers in the clinic, because that’s the first place that a provider or the patient is looking to, hey, we have a social worker in our clinic who can help you with these things. (007) So if it’s in a physician’s practice, then I would say that the physician’s practice should reach out to the palliative care provider and then have them touch base with the
individual.But it can be whatever makes the most sense for that individual and it kind of depends on the setting. But I would say, usually it is someone in a provider office that’s making that connection to say, we have a referral and then the palliative care program reach out to the family member, just because I think sometimes family members are hesitant to make that call for support and this way it’s not put on them to pick up the
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phone and do that. (018)
Respondent organizations used various strategies to ensure patients have access to all the services they need; however, challenges remain in educating patients and clinicians about the benefits of palliative care.
"
Many respondents liked the idea of automated referrals that would be triggered by objective measures because it would increase access to palliative care for many patients.
…So that I think triggers, identifying patients that would benefit from palliative care and
automatically referring them is a great way to do it. I don’t think it should be dependent on a physician referral. (007)
I think it’s wonderful. We have some of our partners that we are actually looking at what are the triggers. We do have one partner that does have a way to automatically refer to us for palliative and for hospice. So, when those things are in place, it leads to less variation, it leads to better access to care, removes some of the barriers. (008)
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The benefits are all over the place. One, we can improve patient wellness. We can extend low impact days of care by keeping people at home. We can reduce hospital admissions and emergency room visits.We can reduce the burden on family members to be responsible for care. We can see less futile care at end of life because of the use of advanced directives and clear goals of care. So I think there's a lot of things out there. (017) Yeah, I think we’d see more patients, I really do. I think it’d be just greater access for patients who actually need it. I really do think that would be the result. And it’s so – I guess if you think about what’s the downside, there really isn’t. Because if you went to see a patient, and they really weren’t appropriate, then you wouldn’t continue seeing them. I think it’s something that only has an upside and not really a downside.(021)
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DISCUSSION Upstream palliative care is an essential component of high-quality serious illness care, but it is limited by lack of qualified staff, reimbursement and payment challenges, and lack of patient knowledge and access. To date research has been limited on hospice care worker perspectives of an upstream palliative care model, despite their experience providing palliative care services to seriously ill patients. Responses from hospice providers show a general willingness to provide upstream palliative care – prior to patient enrollment in hospice. Notably, our study found that some hospice providers are already providing these services. Further, expanding upstream palliative care could alleviate palliative care workforce shortage and smooth transition to hospice for seriously ill people. Increasing access to upstream, coordinated palliative care may offer one strategy to address hospice underutilization. In addition to providing a meaningful service of its own, upstream palliative care is sometimes viewed as a “bridge” to hospice, 19 and early palliative care referral has been shown to lead to longer hospice enrollment. Programs like the Aetna Compassionate Care Program,20,21 Medicare Care Choices Model (MCCM),22 and Hospice Benefit Component for Medicare Advantage plans participating in the VBID Model23 have shown increased access to hospice without increasing costs. However, a few barriers to referral were identified: patient resistance, provider misunderstanding, organizational education, staffing challenges, and reimbursement issues. Some of these barriers, including patient and provider understanding, are consistent with other studies and could be addressed with clear communication.24 For example, a call from the palliative care office could help patients understand the benefits of palliative care and/or hospice and why they have been identified for referral. As palliative clinician workforce shortages are projected to increase in the next 25 years,25 investing in workforce training and retention may help to alleviate the impact of such shortages. In addition, broader insurance coverage of palliative care could allow more flexibility for providers to provide necessary care and reduce time spent seeking alternate funding. Often plans have no distinct palliative care benefit, and when included coverage for specialty palliative care services varies widely.9 Given restrictions for hospice care eligibility, upstream palliative care provision must be perceived as a separate palliative care benefit. Palliative care services should include goals of care conversations, access to durable medical equipment, symptom management, and various spiritual and physical support services. Automatic referrals triggered by objective measures such as disease prognosis, symptomology, and need for psychosocial supports were viewed positively and thought to be a way to increase access to palliative care for many patients. These results are similar to previous surveys of international palliative care experts that showed broad consensus that automatic referrals can increase access to palliative care.26
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Respondents expressed a desire for more payer involvement in identifying eligible palliative patients. However, most were cautious about the growing trend of third-parties acting as direct service providers. Hospice providers raised ethical concerns and noted studies showing how profit-status can affect quality of care. Interviews with clinicians participating in programs in other health care settings have found similar issues, with issues such as communication challenges, a lack of trust, and differing priorities in selecting patients straining relationships between payers and providers.27 Payers are in unique position to hire or contract with third party vendors to alleviate the palliative care gap. However, there was little discussion about innovative payer-health system partnerships or payer collaborations with third-party organizations providing palliative care,28 which have increased in prevalence over the past 5 years. Nevertheless, hospice provider apprehension underscores the need for education about any future payer-based model and open lines of communication, two facilitators also identified in recent VBID Hospice Component evaluations.29 As with any new program, skepticism may be ameliorated with further positive experiences within a payer-based model.
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LIMITATIONS The sample of respondents only included those who were willing to participate in the study, and participants were identified through snowball sampling and reliance on professional associations and networks. Additionally, there was a paucity of participants from diverse racial and ethnic backgrounds, and some perspectives may not have been included due to the homogeneity of the respondents. However, the sample did include respondents from across the United States representing varied geographic perspectives. This study is providing a singular perspective from community-based palliative care providers, and results may not be representative of palliative providers working in other models.
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CONCLUSION
Palliative care has been shown to improve quality of life, symptom burden, reduce hospital admissions, and increase transfer to hospice for patients with serious illness. However, both palliative and hospice services are severely underutilized. Key informant interviews with hospice providers who had experience providing palliative care services identified staffing challenges, reimbursement challenges, and the changing role of payers as barriers to palliative care implementation. Facilitators to palliative care include staff training, policy changes to increase reimbursement, telehealth, and increasing patient referrals to palliative care earlier in patients’ disease trajectories.
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