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palliative care program, which is a team-based service that serves
as an extra layer of support to his existing care providers. His goals
were to stay at home, feel less depressed and anxious, and avoid
another ED visit.
Community-based palliative care (CPC) refers to palliative
care provided outside of the hospital, and evidence has shown
that CPC programs improve patient outcomes and quality of life,
reduce symptom burden, increase survival and decrease health
care utilization. In the United States, CPC has its origins in the
hospice movement, which was legitimized in 1982 by the Medicare
Hospice Benefit. The Medicare Hospice Benefit (MHB) created
per diem (“bundled”) payments for hospices and mandated the
type of care to be provided. The hospice nurse must visit every
two weeks at minimum, and the nurse provides case management
for the patient. She/he works with an interdisciplinary team of
professionals to provide holistic patient care that is overseen by
a physician. Hospice becomes the medical home for a patient
and his/her family, who are considered the unit of care. Care is
delivered wherever the patient calls home. The per diem payment
from Medicare pays for all medications, staff and medical
equipment related to the terminal diagnosis.
Unfortunately, the MHB also mandates that patients are
only eligible if they have an expected prognosis of less than six
months. This requirement has resulted in significant barriers
to hospice care, with the median length of stay in hospices like
Hosparus Health hovering around two weeks. In addition, the
hospice model of care does not assimilate well into the acute care
setting: Medicare Part A pays either hospice or acute inpatient care
for patients hospitalized for their hospice diagnosis. As a result,
patients in the hospital were not consistently receiving quality
palliative care, a reality that was highlighted by the SUPPORT trial
in 1995, which showed that the majority of terminally ill patients
died in severe pain and without their wishes being honored.
Through the grassroots advocacy of providers and the
persistence of the Center to Advance Palliative Care (CAPC),
the palliative care movement began sweeping US hospitals in
the 1990s and 2000s. Academic medical centers were the first
adopters, with 100 percent of AAMC-affiliated hospitals having
a palliative care program. I helped start an inpatient palliative
care program at University of Louisville Hospital in 2006 and an
outpatient palliative care clinic in 2011. Through that experience,
I realized that a key component of care was missing, especially as
we worked to meet the needs of cancer patients who wanted to
continue chemotherapy and other interventions that were often
cost-prohibitive to hospice at home. Population health initiatives
highlighted the benefits of managing patients with palliative
needs across the continuum of care, outside of the hospital setting.
In 2016, I joined Hosparus Health to help start a home-based
palliative care program.
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LOUISVILLE MEDICINE
During the year my patient spent in our home-based palliative
care program, he only had one hospitalization. He received 24/7
phone support and routine monthly visits by a nurse and social
worker, as well as CNA visits twice per week to help him with
grooming and meal preparation. I was able to see him as a palliative
care consultant and manage his shortness of breath, anxiety and
depression. I collaborated with his primary care provider to ensure
he had continuity of care. A trained palliative care volunteer
helped him compile his latest book. He was ultimately referred
to the hospice program because of a presumed six months or less
prognosis, and he was re-enrolled.
Thankfully, my patient had the resources to pay out-of-pocket
for home-based palliative care, a service that is currently not
universally provided by insurers. In order for this innovation to
make a significant impact, payors must recognize and meet the
need for palliative care at home. Our health care system must
improve the quality of care for chronically ill and medically
complex patients who do not receive hospice. The American
Academy of Hospice and Palliative Medicine and the Coalition
to Transform Advanced Care have worked tirelessly to develop
proposals that address the needs of seriously ill patients. These
have been presented to the Physician-Focused Payment Model
Technical Advisory Committee (P-TAC), and the Department
of Health and Human Services will hopefully approve a model
soon. Until then, we will rely on community innovators to grow
community-based palliative care in the hope of improving the
care of seriously ill patients and their families.
Dr. Earnshaw is the Senior Hospice and Palliative Medicine Physician
for Hosparus Health and Associate Clinical Professor at the University
of Louisville.
References:
Kamal, Arif, MD, et. al. Community-Based Palliative Care: The Natural
Evolution for Palliative Care Delivery in the U.S. J Pain Symptom Manage 2013;
46: 254-264.
Center to Advance Palliative Care. Identifying High-Risk Patients Early by
Diane Meier, MD. Available from https://palliativeinpractice.org. Accessed
6/23/2016.
Connors, Alfred F. Jr, MD. A Controlled Trial to Improve Care for Seriously
III Hospitalized PatientsThe Study to Understand Prognoses and Preferences
for Outcomes and Risks of Treatments (SUPPORT). JAMA. 1995;274(20):1591-
1598.
Fierce Healthcare. HHS sets 3 priorities for new physician-focused payment
models by Joanne Finnegan. Available from www.fiercehealthcare.com.
Accessed 1/18/19.
Lustbader, Dana, MD, et.al. The Impact of a Home-Based Palliative Care
Program in an Accountable Care Organization. J Pall Med 2016: 1-6.
Youens, David and Moorin, Rachael. The Impact of Community-Based Palliative
Care on Utilization and Cost of Acute Care Hospital Services in the Last Year of
Life. J Pall Med 2017; 20 (7): 736-744.