Pre-hospice aid
focuses on overall quality of life
by Kim Hayes, AARP,
May 31, 2017
Palliative care can improve patient satisfaction, cut health
care costs and even extend life for seriously ill patients.
En español |
Realizing that seriously ill patients often do better when they can stay in
their own homes and receive coordinated and personalized treatment, growing
numbers of health plans, physicians and medical facilities are offering
pre-hospice, home-based
palliative care to their patients.
Home-based plans typically integrate
multidisciplinary care teams that include physicians and nurses, social
workers, mental health professionals and chaplains who visit patients in their
homes and offer tailored treatment plans focused on improving quality of life.
The results can benefit patients and their caregivers and are cost-effective
for the health care system, according to experts.
Priority Health, which has nearly 800,000
members in Michigan, runs health benefit options for employer groups and
individuals, including Medicare and Medicaid plans. About five years ago,
Priority Health established the Tandem365 initiative, through which a
multidisciplinary team provides free care to patients who are seriously ill and
unable to seek outside medical help due to cost or immobility. The
initiative has shown promising results, including:
- a 38 percent decrease in
inpatient stays
- a 52 percent decrease in emergency department visits
- a 35 percent decrease in total cost of care
- 46 percent fewer specialty care visits
Palliative care
combined with traditional care
“Most people lump palliative care in with hospice,
but there are distinct differences between the two,” says Greg Gadbois,
Priority Health's medical director. “With palliative care, curative care is
also OK. The big goal is to have that discussion with the patient of: 'What is
important to you? What do you want us to do, or what don’t you want us do?'
Most say they want to be home with their family and in peace. Palliative
is the low-tech, high-touch opportunity to learn what the patient wants and
needs."
Having a home-based team also offers a new
level of understanding for a patient’s situation, he says. “For doctors, they
see a patient in their office for 20 minutes and don’t get a full picture. I‘m
a family doctor, and when elderly patients come to see me, they are dressed in
their Sunday best and will say that everything is fine. They want to impress
their doctors. But in home settings, you can’t hide those issues and problems.”
Members of a palliative care team may see that
the patient is in financial trouble and deciding between paying for medications
or their heat bill. Or that the patient is a hoarder with a fall risk when
walking through the house. These social determinants of health can provide
important context to their overall health care plan, Gadbois says.
Palliative care also offers medical
professionals the opportunity to discuss risks and benefits of traditional
treatment plans, Gadbois says, noting that a study published in the New
England Journal of Medicine showed that lung cancer patients who
received early palliative care lived longer than those who didn’t. “It speaks
to the fact that some treatment can be pretty toxic.”
Stereotypes remain that palliative care means
giving up on extending life, but that perception is changing with increased use
of the programs, Gadbois says. Retraining doctors to talk to their
patients about end-of-life options is crucial. "We never received
training on end-of-life
discussions, and we are not comfortable talking about it. Death is
seen as a failure. But the end is part of our journey. It is important to do a
good job helping the person to transition from this world to the next with as
much dignity as possible.”
Barriers to
palliative care
Reimbursement issues can make palliative care
tricky for doctors, who are paid based on productivity. “Taking 45 minutes to
talk to a patient about palliative care is a lifetime in their world,” Gadbois
says. However, the Center for Medicare and Medicaid Services is now paying for
advanced care planning discussion, and some health plans are moving towards
adopting a palliative care system.
For managed care plans, palliative care hits
the Institute for Healthcare Improvement’s “Triple Aim” of health care:
- improving the patient
experience of care (including quality and satisfaction)
- improving the health of populations
- reducing the per capita cost of health care
“We aren’t denying care. We are eliminating
unwanted care, and we see fantastic outcomes. Patient satisfaction rates are
through the roof,” Gadbois says. However, he recognizes that doctors'
offices are losing revenue, so a better way to reimburse delivery systems must
be found so that the right care is incentivized. “That is the bigger lift right
now. We are in the process of moving in that direction, but no where near where
we need to be.”
Support for
caregivers
“Caregiver burnout is a challenging issue for
many families, and having access to home-based care provides another layer of
direct support, along with professional-level advice. Social workers and others
on the care team play a crucial role in coordinating community support
options," says Bruce Smith, executive medical director for
Regence BlueShield in Washington state.
“We believe caregiver support is so essential
for the patient that our palliative care benefit offers caregiver support
whether the person is a Regence member or not,” Smith says.
Regence, which offers coverage in Idaho,
Washington, Oregon and Utah, launched a palliative care program in 2015 that
includes advance care planning, collaborative care coordination and in-home
counseling. It is open to anyone with a serious medical illness and provides
caregiver and psycho-social support, as well as non-medical needs such as
transportation and food.
“Having the ability to bring a coordinated
model of care to a person in their own home can be a godsend for those who may
have difficulty getting to an office appointment due to their health condition
or other barriers,” Smith says. “Home-based programs take on the responsibility
of meeting the patient’s needs rather than asking the patient to meet the
doctor’s needs.”
The trend toward palliative care is growing in
part because health insurers and medical groups are being held accountable for
both quality outcomes and costs, Smith says. “Since a well-run home-based
care program can improve quality of care and reduce overall costs, more and
more organizations are offering home-based care.”
California leading
the charge
The Hill Physicians Medical Group in San
Ramon, Calif., has partnered with Blue Shield of California and Snowline
Hospice on a home-based pre-hospice plan, which they say has numerous
benefits.
“When people have a serious illness, they and
their families often
have a host of questions and needs that are best addressed by an
interdisciplinary team,” says Terry Hill, vice president for performance
strategy at Hill Physicians. “There's a world of difference between trying
to identify those questions and needs in a physician's office versus at home,
where the patient and family feel more in charge and the clinicians can take in
the whole picture.”
Word of mouth is helping palliative care to
grow, Hill says. “People who have experienced or heard about home-based
palliative care tend to be enthusiastic and vocal, so word is getting out, and
health care delivery systems are beginning to realize that these programs can
reliably yield positive clinical and financial outcomes.”
Many of the top palliative care
programs are located in California. “California is blessed with a number
of factors that facilitate innovation in palliative care," he says.
"It helps to have medical groups with a long-standing commitment to
population health and leaders from the state's medical and public health
schools who are palliative care champions. The Coalition for Compassionate Care
of California facilitates a shared community for palliative care learning, and
foundations have provided strategic support.”
Paying for
palliative care
Barriers to wider implementation of palliative
care nationwide include lack of reimbursement by Medicare, says Torrie
Fields, senior program manager of palliative care for Blue Shield of
California. "While many commercial health plans and Medicaid plans, like
those in California, have begun to innovate and finance palliative care
programs, the majority of those who would benefit from palliative care are
still covered under Medicare fee-for-service."
Palliative care can reduce expensive and
unwanted emergency department visits and hospital admissions, so it makes
financial sense for a payer, health plan or delivery system with responsibility
for the total cost of care, Hill says. “But high-touch services such as those
provided by palliative care teams are themselves costly and beyond the
resources of most organizations that do not share in the cost savings that
palliative care makes possible.”
However, all patients and caregivers can have
advance care planning conversations, starting at their doctor's office.
"Not all health plans have palliative care programs, but some do —
including access to multidisciplinary care teams and even extra covered
benefits. Patients and caregivers should ask whether or not palliative care is
covered by their health plan and whether it requires a copay. This will allow
patients and families to make the most informed choice about how to access
palliative care," Fields says.
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