AAHPM Fall Quarterly 2011 : Page 12
WHERE IS PAL
WHERE IS PALLIATIVE CARE IN THE READMISSIONS BOOM?
In April 2011, Donald Berwick, MD, administrator of the Centers for Medicare & Medicaid Services, announced the creation of a billion-dollar quality initiative, Partnership for Patients. Half of those dollars were allocated to support the work of community coalitions, including hospitals, to reduce 30-day hospital readmission rates. This program, called the Community-Based Care Transitions Project (CCTP), highlights a growing national focus on avoiding preventable readmissions—both for their costs and inefficiency and for their negative impact on the lives of patients with serious illness. Beginning in 2013, hospitals will be penalized in their Medicare reimbursement for higher-than-average readmission rates.<br /> <br /> A number of quality initiatives, including Dr. Eric Coleman’s Care Transitions Program,1 Project RED (Re-engineered Discharge)2 at Boston University Medical Center, and the Society of Hospital Medicine’s Project BOOST (Better Outcomes for Older adults through Safe Transitions),3 are nationally recognized strategies for reducing readmissions. Participation in these programs is given preference in CCTP grant applications. Project BOOST recently added palliative care as one of the “eight Ps” for assessing a patient’s risk for rehospitalization, but it seems little more than an afterthought given the national fixation on readmissions.<br /> <br /> When patients enroll in hospice care, their days of hospitalization might be expected to go down, thanks to hospice’s 24-hour on-call capacity, ability to quickly deliver services and needed prescriptions to the patient’s home, and the shift in goals of care. Dedicated hospice and palliative care social workers are adept at connecting patients and families with other resources in the community. Palliative care practitioners also have the needed skills for goals-of-care conversations, complex symptom management, and honest discussions about prognosis.<br /> <br /> Where are America’s hospice and palliative care advocates in the current national conversation about preventing hospital readmissions? Could they have a higher profile in promoting more effective hospital discharges and care transitions? If they have something to contribute, how can they ensure that it is included in the transformation of the healthcare system under new delivery models such as accountable care organizations?<br /> <br /> The challenge in realizing such an impact, says Diane Meier, MD FACP FAAHPM, director of the Center to Advance Palliative Care at Mount Sinai School of Medicine in New York City, is the lack of data convincingly demonstrating that palliative care consultations in the hospital reduce 30-day readmission rates—as there is for palliative care’s documented impact on costs of care within the hospital. “I think that is an urgent, high-priority research question for our field. I am concerned that we’re going to miss this window of opportunity, even though our patients are a big part of the readmission problem,” she says.<br /> <br /> Dr. Meier encourages palliative care professionals to insist on having a seat in the planning teams that are now meeting at many hospitals to explore improving 30-day readmission rates. Not all potential readmissions are appropriate for palliative care, she says, “but many are. And for those with complex diseases and progressive illnesses, we are a key component to helping patients stay safe in the community and avoid preventable rehospitalizations. But the only way to have input is to get to the table, pull up a chair, and contribute to devising solutions.” More than that, Meier adds, “if palliative care teams are not actively involved in building partnerships and relationships with the providers in the community that are needed to ensure safe, sustainable, and appropriate discharge plans, then they are not in concordance with the standards guiding optimal quality of palliative care.” The National Quality Forum (NQF)’s “Preferred Practices for Palliative and Hospice Care Quality”4 addresses this issue, and it will become more explicit under The Joint Commission’s new advanced certification program (see page 23) in palliative care,5 Dr. Meier says.<br /> <br /> Putting Readmissions on Hospice and Palliative Care’s Radar Screen<br /> Readmissions absolutely should be on the radar screens of Academy members, says Jean Kutner, MD MSPH FAAHPM, head of general internal medicine and a palliative medicine physician at the University of Colorado School of Medicine. Managing care transitions for patients with complex illnesses and making realistic care plans congruent with their wishes “is one of the many things we’re good at. Rehospitalization is the current lexicon that gets people’s attention and is a way of framing and making relevant something we’re already doing. But we’re in danger of being left out of the planning and having our health systems reinvent the wheel without us.”<br /> <br /> Dr. Kutner sits on a cross-setting quality committee at the University of Colorado Hospital, where she represents both internal medicine and palliative medicine. “Our committee defined three high-priority areas for improving patient care, and care transitions is one of them,” she reports. “We’re charged to come up with processes for improving transitions of care. It’s a big and complicated issue, which is why palliative care needs to step to the fore.” Palliative care professionals working in the hospital have long noted their frustration at developing comprehensive plans for patients’ discharges, only to see them fall apart after the patients go home.6 But they may not be able to follow their patients home or field calls from patients who run into trouble after discharge, even though networking and collaborating with community providers of palliative care—if there are any—may be more attainable. This dilemma is similar to what hospitalists face when they are asked by their health systems to help reduce preventable readmissions by extending their role beyond the hospital’s four walls.<br /> <br /> “Hospital-based palliative care professionals generally don’t follow people into community-based palliative care and don’t have the capacity to do so,” says Dale Lupu, PhD, a quality-based consultant to AAHPM and other palliative care-related organizations. A major barrier is the field’s workforce shortage. The hospital is an obvious place to start building systems of patient-centered, community-based care, she adds. “But the real question is what do these patients need to stay in the community? Often the answers are simple things like transportation or help with medication management and activities of daily living, which aren’t traditionally considered medical services.”<br /> <br /> More Venues for Palliative Care in the Community<br /> “It’s not a reality yet that readmissions cost hospitals money, but it’s coming soon,” notes Amy Abernethy, MD FAAHPM, associate professor of medicine and a medical oncologist at Duke University. “This is a great opportunity for conversations with our hospitals. I sit on a hospital readmissions committee, and when we looked at reasons for readmissions among our solid tumor service, we found that the solutions lie in a category that the hospital calls ‘supportive oncology.’ That requires a sophisticated understanding of supportive oncology’s toolbox—and why it’s really just about better palliative care.”<br /> <br /> Reducing readmissions also requires more venues for palliative care in community settings. Christine Ritchie, MD MSPH FACP, palliative medicine physician at the University of Alabama-Birmingham, says outpatient clinic–based palliative care is a nascent growth area for the field. “Some patients want to die in the hospital; many don’t. The bigger issue is how to get palliative care more fully integrated into the care continuum. This is the perfect time for us to bring this issue to the table—talking to health systems and payers and making sure people understand our role in supporting patients in and out of the hospital. It is important to serve the patients we can help the most—those with complex illnesses and high illness burden—and continue to be relevant.”<br /> <br /> Dr. Ritchie has a randomized, controlled trial testing how to use information technology systems to support patients with complex medical conditions as they transition from the hospital to home-based care. “Readmissions is an area I look at all the time, trying to develop a platform and applying it to advanced illness. This is important for a lot of reasons. The patients we see in the hospital and the community are the ones at the highest risk for readmissions,” she says.<br /> <br /> Palliative care professionals need to learn about these issues and gain comfort with the language of care transitions, Dr. Kutner says. “Then we can start raising the awareness of those around us. Our palliative care team will be making a presentation to our hospital board about these issues at the end of this month,” she reports. “Everyone in the hospital is always looking for volunteers to be on their committees and surely one of those most relevant to us is the readmissions committee.”
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