Becker's Clinical Quality & Infection Control

20 Sign up for the Free Becker's Clinical Quality & Infection Control E-Weekly at www.beckersasc.com/clinicalquality. Palliative Care: Why It Has Become a Growing Specialty Within Hospitals By Bob Herman T here are few certainties in healthcare, but one is that hospitals will generally be facing an increasingly older population. And with age comes more chronically and severely ill patients. In addition, he says it is a misconception that palliative care teams are "agenda-driven" or try to limit care to people. "From personal experience, that is just not what we do," Dr. Risser says. According to statistics from the federal government, the number of people in the United States who will be older than 85 by 2030 is expected to double to 8.5 million. To complicate matters for hospitals, most of those older, critically ill patients will be in hospitals, as nearly all Medicare beneficiaries spend at least some time in a hospital during their last year of life. In fact, about 27 percent of Medicare dollars are spent on patients in their last year of life, and roughly 25 percent to 32 percent of patients die in hospitals. A typical day for the Regions Hospital palliative care team involves morning rounds on the patient census. The team goes through their patients and discusses each patient's needs — medical, social, spiritual. From there, the team will go see patients as a group (if time permits, individually if not) to get a sense of what care should be coordinated and what the patient and family want. This is a large responsibility for today's hospitals and health systems, and will be an even bigger issue in the future. Diane Meier, MD, director of the Center to Advance Palliative Care, the national authority on palliative care programs in U.S. hospitals, says hospital executives need to recognize that only 5 percent of their patients drive 50 percent of all spending. Many within this highly concentrated group of people need some type of care management, and within that, palliative care could play a huge role. "As we move away from fee-for-service and toward capitation, global budget and population management strategies, the business model requires management of that 5 percent," Dr. Meier says. "If you can't manage that 5 percent, you will go under financially. They drive so much of the spending and are such big users of the healthcare system." Palliative care — what it is and is not Palliative care is still a relatively new movement, considering the long history of healthcare. Jim Risser, MD, medical director and head of palliative care at St. Paul, Minn.-based Regions Hospital, says the specialty has really galvanized in the past five to 10 years, and the actual definition of palliative care revolves around the comforts and desires of the patient. More specifically, he says palliative care is a service carried out by a multidisciplinary team to help patients who have advanced, though not necessarily imminently terminal, illnesses such as cancer, congestive heart failure and Alzheimer's disease. A hospital with a palliative care program gives those types of patients various patient- and family-centered options to help cope with the serious illness, and usually there is a major emphasis on pain management, advanced care planning and the patient's quality of life. The palliative care team is made up of its core members — physicians, nurse practitioners, social workers and chaplains — and incorporates other disciplines like pharmacy, nutrition, ethics, hospice and complementary care as deemed necessary. Dr. Risser has been at Regions Hospital, part of HealthPartners, for several years, and in October 2011, Regions became one of the first hospitals to have its palliative care program certified by The Joint Commission. He has seen his hospital's program grow over the past eight years, and he says it's vital to not confuse palliative care with hospice care. "We continue to challenge these notions that our patients are dealing with end-of-life issues in the immediate future," Dr. Risser says. "That situation is more consistent with a hospice-type of care. I think a lot of times we get lumped into the hospice movement — and we share a lot of the philosophies, such as spending a lot of time with the patient and making them more comfortable — but palliative care is farther upstream than hospice. With palliative care, if you want to pursue more aggressive medical procedures, let's sit down and describe the benefits and burdens." Joe Contreras, MD, chairman of the Pain & Palliative Medicine Institute at Hackensack (N.J.) University Medical Center, agrees with Dr. Risser. Dr. Contreras helped HackensackUMC become the first Joint Commissioncertified palliative care program in New Jersey in January, and he says palliative care in hospitals is not synonymous with hospice, nor is it a care-limiting panel. Further, palliative care is not just about dissecting the situation of a disease or illness. It's about providing quality care and symptom management along with all other treatment measures, whether aggressive or comfort-based. "It is important to understand palliative care is very different from other subspecialties of medicine. It is person-based and not disease- or organsystem-based," Dr. Contreras says. "It's a new paradigm for hospitals because we [palliative care specialists] are of the mind-body-spirit approach. We are not being asked to remove an organ or consult because the kidney is not functioning well. We're being called in because we are trying to improve an ill person's quality of life and address their suffering." The case for palliative care Dr. Meier has led the Center to Advance Palliative Care since the late 1990s, when it started as a program of the Robert Wood Johnson Foundation. Dr. Meier, who also founded (and until 2011) served as director of the Hertzberg Palliative Care Institute at The Mount Sinai Hospital in New York City, says palliative care has gained traction in the hospital arena for a couple reasons. First, many patients who had suffered severe and chronic illnesses had looked for alternative ways to treat their pain and better manage symptoms and daily care needs at home, but hospitals and health systems have not always offered an alternative. Instead, hospitals may have focused their efforts on what they can do immediately in the acute-care setting. As mentioned earlier, Medicare and healthcare costs rise significantly for those who are older and for those who suffer severe and chronic illnesses in the acute-care environment, and that is another major reason why palliative care has grown. Dr. Meier believes palliative care has caught on at hospitals and health systems because there is "so much excess spending on the acute-care side." In fact, Dr. Meier and CAPC officials say patient-centric palliative care — through improving quality of care and person-driven care — can actually save hospitals and the healthcare system money in the long run due to shorter length of stay or lower costs per day. For example, in a given hospital with 20,000 to 30,000 admissions per year, roughly 2 percent end in death. Dr. Meier says if roughly four or five times that number are complex cases that are vulnerable to readmission, roughly 8 to 10 percent of patients may have palliative care needs and can be more effectively treated in a more appropriate setting.

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