By Healthforce Center Associate Director of Research Joanne Spetz and Center to Advance Palliative Care Director Diane E. Meier
Background
Palliative care provides patients with serious illness with relief from symptoms such as pain, shortness of breath, fatigue, and depression. The discipline’s aim is to support the best possible quality of life for patients and their family caregivers, regardless of whether the patient is expected to recover, live with the illness for an extended period of time, or is nearing the end of life. [1,2,3,4] Although hospice is a form of palliative care specifically for those dying soon, palliative care eligibility is determined by patient and family need and not on prognosis. The Institute of Medicine has recommended that all Americans with serious illness have access to palliative care services provided by well-trained transprofessional teams.
In 1998, 15 percent of US hospitals with over fifty beds had a palliative care program. The percentage had risen to 67 percent in 2013[5], and these programs are now spreading into community health care settings such as nursing homes, office practices, and home care services.[1,6] Growth has been driven, in part, by evidence that palliative care improves patient outcomes and satisfaction, while reducing emergency department visits and hospital costs associated with preventable symptom crises.[1, 7, 8, 9, 10, 11, 12, 13, 14]
The Research Question
Although non-hospice palliative care can be provided in all settings, the predominant model in the US currently is the hospital consultation team [3]. According to the National Consensus Project for Quality Palliative Care Guidelines [2] and the Joint Commission Advanced Certification Program for Palliative Care, the core palliative care team should include a physician (a doctor of either medicine or osteopathy), an advanced practice or other registered nurse, a chaplain, and a social worker—all with specialized training or clinical experience in palliative care.[15] In addition, a consensus panel convened by the Center to Advance Palliative Care (CAPC) recommended that palliative care programs have specific funding for a board-certified physician.[16] Finally, the National Consensus Project for Quality Palliative Care has advised that programs should have on-site staffing coverage during normal business hours and telephone coverage at all times.[2]. There has been little research on program team staffing and whether those teams meet national guidelines. We analyzed national data on staffing in hospital-based palliative care programs and assessed whether there are important staffing differences by program characteristics, hospital characteristics, or region.
Key Findings and Policy Implications
1) One-third of hospital-based palliative care consultation programs do not have recommended 24/7 coverage, that is, personnel available on-site during weekday business hours and, at a minimum, by telephone at all times.
2) Only 25% of programs have the complete interdisciplinary team recommended for quality for palliative care services.
3) Rapid and sustained efforts in education, financing, and health systems management will be required to prepare the US health workforce to meet the palliative care needs of a growing aging population living with serious and complex chronic illnesses.
Policy Recommendations for the Road Ahead
Meeting Demonstrated Clinical and Workforce Needs
The proportion of hospitalized patients that is reached by palliative care programs is in the scant single digits. Although the “right” penetration level has not been determined, this is likely far below the actual need. A recent study estimated that 13.8 percent of intensive care unit admissions met criteria for palliative care consultation,[18] and a study in a large cancer center estimated that one-third of hospitalized cancer patients should receive a palliative care consultation.[19] Fully one-third of palliative care programs did not have recommended coverage—personnel available on-site during weekday business hours and by telephone at all times, and because the survey data were voluntarily reported and overrepresented programs in larger hospitals, it is likely that they have higher staffing levels than the average among all US hospitals, leading us to overestimate the adequacy of palliative care program staffing. Palliative care physicians are in short supply; it has been estimated that 18,000 more of them would be needed just to staff the number of existing programs in 2009 at recommended levels[20]. Growth in hospital and community palliative care services since 2009 suggests that the shortfall is far greater.
Early and Mid-career Education
Current undergraduate and graduate professional training programs do not provide adequate basic clinical education in palliative care for all health professionals who care for seriously ill and complex high need patient populations. Such training should incorporate not only pain and symptom management, communication about what matters most to patients and their families, and coordination and communication of care over time and across settings, but also interprofessional teamwork skills. All clinicians including medicine, nursing, social work, rehabilitation, and counseling, require this grounding in the complex needs of the highest risk, highest cost patient populations.
Since the great majority of practicing clinicians are midcareer, midcareer palliative care education is prerequisite to improving access to timely and high quality palliative care services. Some leaders in the palliative care field have recommended a midcareer certification for so-called palliative care ‘champions’ who could provide palliative care consultations when needed, engage in case reviews with board-certified palliative care physicians, and participate in self-paced education.[4] Both the acute care and community settings offer appropriate training platforms for education in palliative care,[21] and online and video education programs have proved effective in developing palliative care knowledge and skills.[22, 23, 24, 25] To encourage uptake of palliative care education opportunities, state licensing boards could encourage or require palliative care education as part of continuing education requirements and re-licensure.
Health Systems Management
Health system managers responsible for ensuring high value care to a high risk high need population must ensure that palliative care is available, adequately staffed, and able to identify and serve at risk patients in a timely and high quality manner.[3] For example, checklists have been developed to enable early identification of patients in need of palliative care consultation.[18, 19, 25] Health system and population health managers should ensure that their palliative care programs collaborate effectively with related services including community-based advance care planning campaigns, embedded and telephonic case management, and interventional pain services.
Legislative Action
The Palliative Care and Hospice Education and Training Act, now pending in Congress, would amend the Public Health Service Act to increase the number of palliative care faculty members in medical schools, nursing schools, social work schools, and other programs. The Bureau of Health Workforce within the Health Resources and Services Administration can play a role in supporting palliative care education through its grants programs. Additionally, the Centers for Medicare and Medicaid Services (CMS) has established programs that may support reimbursement policies that help encourage palliative care, such as growing linkage of payment to value, approval of separate payment for advance care planning and care coordination, and recent provisions to allow hospices in the Medicare Care Choices Model to offer patients supportive services while they are continuing to receive curative treatment. Rapid and sustained efforts in education, financing, and health systems management will be required to prepare the US health workforce to meet the palliative care needs of a growing and aging population living with serious and complex chronic illnesses.
About the Authors
Joanne Spetz is the associate director of research at Healthforce Center at UCSF. In addition, Dr. Spetz is a professor at the Philip R. Lee Institute for Health Policy Studies, Department of Family and Community Medicine, and the School of Nursing at UCSF. Dr. Spetz’s research focuses on the economics of the health care workforce.
Diane E. Meier is director of the Center to Advance Palliative Care (CAPC), a national organization devoted to increasing the number and quality of palliative care programs in the United States.