Hospice and Palliative Medicine

A Palliative Care Summit was recently convened in Philadelphia by the School of Population Health at Thomas Jefferson University. It was described as the “First National” and the “Leading Forum on Palliative and End-of-Life Care”.

An impressive array of speakers over the two days. Diane Meier,MD, Sean Morrison, MD, Don Schumacher, David Wennberg, MD, Christine Richie, MD, Terri Maxwell, PhD,APRN, James Cleary, MD.,Todd Hultman,PhD,APRN to name but a few. A roster of thought leaders in the field. Compelling cases were made during the presentations on why hospice and palliative care (is/are?) the solution to many of the health care industry’s woes.

Meanwhile, just next door, other industry thought leaders were offering compelling cases on why “medical homes” or ‘expanded chronic care models” or “mobile technology” were desirable solutions for transformation of the health care system.

In other words, competing, or one might say, conflicting visions. These competing/conflicting visions exist across specialties, and within them.

Dr. Morrison addressed this issue when he stated that the public and professionals are confused by references to hospice and palliative care , as if these were two distinct fields or sectors.

While my training is as a health executive, I’ve spent much of my professional career advancing the work of palliative care/hospice professionals and organizations. So I pay closer attention to the hospice/palliative care field, and how it may best fit into the larger health care system. And as Dr. Morrison stated directly, and others commented more indirectly, while progress has been made over the past 15 years, the institutional culture of dying in the US has not dramatically changed. I refer to palliative care as one parts accomplishment for every three parts of potential. Yes, we have a long way to go, indeed.

At the end of the Summit, I was left with a nagging question: If hospice and palliative care are such an obvious solution, then why hasn’t the “art” and “science” of hospice and palliative care spread more quickly and widely than it has? No simple answers to be sure. Yes, many of the speakers offered calls (some powerful) to action. Yet calls for action have been sounded for the past 15 years, with some, but most would argue, insufficient progress. Why? The promise of palliative care to improve late-life care has been stymied by a highly fragmented field of hospice and palliative care where stakeholders are perpetually “staking”out their ground.

Some suggestions for the Second National Palliative Care Summit. Let’s have discussions around:

*How nursing AND medicine can best collaborate to improve access to palliative care in all settings across the community.

*What NEW organizational models might best bring together key stakeholders in late-life care within a community?

*What can be learned from communities whose late-life care practices make them exemplars?

Finally, we need a unifying campaign to improve late-life care in the US. Here’s a suggestion. The 30/30/30 Campaign. A national campaign carried out locally/regionally.

Something like the following:

*No more than 30% of deaths occur in hospitals.

*At least 30% of deaths in hospital are consulted by palliative care specialists.

*No more than 30% of patients who die will be enrolled in hospice for 10 days or less.

Your comments, ideas, feedback are, as usual, invited.

We [the CMS] believe the role of the physician within hospices has been undervalued, and we would like to see the physician’s participation increase in the care of long-stay patients. That’s one of the messages to take away from the CMS regulation mandating physician (or nurse practitioner) face-to-face encounters to certify a patient’s continued hospice eligibility. The Medicare program reimburses a hospice nearly $30,000 over a six-month period to provide for the total healthcare needs of a patient with advanced illness- a single physician visit to that patient’s residence over that period isn’t too much to require, is it?

To me, it seems likely that such patients would benefit from a care planning visit by a physician. After all, the distinguishing feature of hospice care from most other care covered by Medicare is its collaborative nature, and the primacy of the interdisciplinary team.

Such care, of course, lies at the core of palliative medicine.

Rather than treating this regulation as a compliance issue, hospice executives, and physicians, would do well to incorporate physician recertification visits into their clinical practice patterns. One can be confident that patients, and their families, will appreciate the value of these visits.

Recently, a family member passed away after a broken hip confined her to a skilled nursing facility. A hospice program served her during her final three months. During that time, she was not seen by a hospice and palliative medicine physician. And while her (and the family’s) hospice experience was positive, the interdisciplinary team concept seemed incomplete without a single bedside appearance from the physician.