Tim Cousounis

What is the best way to improve the practice of palliative care?

The practice of palliative care, by physicians and advanced practice nurses, has gradually moved into the mainstream of American health care. While there is little debate over the need to improve late-life care, especially within acute and long-term care institutions, there continues considerable discussion over how to best improve it.

Unlike most other medical specialties, palliative care is not reliant upon the effective formation of physical capital (diagnostic and therapeutic equipment using advanced technology) for its practice. To the contrary, it is totally reliant upon the effective formation of intellectual capital. Its effective formation is integral to the success of palliative medicine practices.

You’re thinking that palliative care is the lengthened shadow of a practitioner’s knowledge of clinical best practices. And, you’d be on the right track, for the provision of palliative care is based upon one component of intellectual capital, the know-how, skills, and competencies of the practitioners. Whether a practice or program has sufficient number of practitioners to render this knowledge-based care, first-hand, throughout the community, is a critical decision whose studied deliberation can tip the scales in a program’s outcome.

Two other components make up a program’s intellectual capital:

1. Structural capital (or infrastructure) : those workflow processes (automated or manual), revenue cycle practices, databases, and routines that enable effective day-to-day operations.
2. The other is customer capital - or goodwill to many - the program’s relationship with its referring, and non-referring medical community, payers, partners, and, of course, its patients.

The effective formation of these three components leads to the desired result – development and sustainability of the practice, and its affiliated programs. So, what’s my point about being undercapitalized, you’re likely wondering? Most programs, and by extension the practices that support them, are subsidized by hospitals, hospices, or grants and philanthropy. This support is often renewed annually, thus demanding of the program’s managers a yearly impact statement of the program’s results. Long-term sustainability depends upon revenue generation, a business process oft shortchanged, at best, or neglected, at worst. This structural capital is often borrowed from the parent organization, whose resources, no matter how well intentioned, rarely offer the sharp focus, attention, and insider know-how so necessary to effective revenue capture.

OK, there may be a shortage of intellectual capital, but overcommitted? Palliative care specialists, were they to be queried, would remark that they don’t have sufficient time to develop the program. Programs report either of two situations – that palliative care has been widely adopted as the standard for late-life care in the community, and that there aren’t sufficient qualified staff to respond to referrals, or that palliative care has not sufficiently diffused throughout the community and a stronger referral base needs to be built. In either instance, what's lacking is a critical mass. Hospices provide part of the answer. So do hospital-based palliative services. Only Accountable Palliative Care Organizations (APCOs), through their effective formation of intellectual capital, have the capability of providing the entire answer.

Grand Junction - An Exemplar Palliative Care Community

President Obama held a town hall recently in Grand Junction, Colorado. To healthcare reformers, Grand Junction, CO., is one of the areas of innovation -- a place that provides high-quality healthcare at a fraction of the costs in most other communities. And, according to some experts, Grand Junction chalks up some impressive statistics. Only 12% of Medicare patients required readmission 30 days after a hospital visit, as opposed to the nationwide rate of 20%. Children on Medicaid in the HMO are four times as likely as other Colorado Medicaid children to receive all immunization treatment -- and adults on Medicaid were up to 10 times as likely to get comprehensive diabetes care.

How does Grand Junction stack up for its palliative care practices? The Community Palliative Performance Profile, compiled by DAI Palliative Care Group, graded Grand Junction as an A-plus (an exemplar community). Why did Grand Junction earn this superlative? For starters, less reliance in the final months of life upon intensive care (less than half of national average) and one of lowest percentages of deaths occurring in a hospital (20.7%). And hospice enrollment nearly 30% greater than the national average. Is it mere coincidence?

Palliative Medicine Physician Performance

I'm often asked (usually by hospice executives) how the performance of palliative medicine physicians can be best evaluated. What they're really asking is: how do I know if the hospice's investment in its medical staff is paying off? While there is no single, or simple, answer, there are ways. I find that most palliative care programs (including hospices) have only recently added to their medical staff (up to this point the majority of physicians practicing palliative medicine have been in part-time positions as hospice medical directors in the traditional sense), and so a strong need for an ongoing performance evaluation program has not been perceived.

But as palliative care organizations move toward a model that relies more on an expanded (and some would say progressive) role for physicians, performance management takes on greater importance.

To underscore this point, the Joint Commission recently introduced a standard named Ongoing Professional Practice Evaluation (OPPE). The intent of the standard is that organizations are looking at data on performance for all practitioners with privileges on an ongoing basis rather than at the two year reappointment process, to allow them to take steps to improve performance on a more timely basis. While this standard applies specifically to hospitals, hospices and palliative care programs should take note.