The field of palliative care is a relatively recent entrant to the U.S. health care landscape.
For those who may not know, palliative care is a new team-based medical specialty that focuses on relief of the pain, symptoms, and stresses of a serious illness in order to achieve the best possible quality of life for patients and their family caregivers.
Eligibility is based on patient and family need, and is independent of prognosis. Interdisciplinary palliative care teams assess and treat symptoms; support decision-making and help match treatments to informed patient and family priorities; provide practical aid for patients and their family caregivers; mobilize community resources to ensure a safe and secure living environment; and promote collaborative models of care across a range of care settings (i.e., hospital, office, home, and nursing home). Palliative care is offered independent of prognosis and simultaneously with disease directed therapies for persons living with serious, complex, and life threatening illness.
In the mid 1990’s palliative care was developed in recognition of the need to enhance the quality of life of seriously ill patients and their family caregivers. A growing body of research demonstrates that palliative care delivered through a broad range of models and care settings improves quality of life, quality of care, and in doing so, reduces hospital costs. Growing attention to best care of high-risk high-cost persons with complex and serious illness in the wake of the Affordable Care Act has resulted in considerable interest in improving access to palliative care for this population.
The Center to Advance Palliative Care and the National Palliative Care Research Center have been tracking growth in the prevalence of hospital palliative care services in the U.S. since 1998, and released our latest report of 2014 data on October 1, 2015. Our findings suggest continued growth in the prevalence of hospital palliative care programs, especially in the largest hospitals that serve the majority of U.S. patients. Gaps in access persist, however, associated with geography, hospital ownership, hospital size, and other hospital characteristics.
The Good News: Universal Access
Steady growth in the number of hospital palliative care programs has resulted in near universal access to palliative care in hospitals with more than 300 beds (90 percent) as well as in U.S. teaching (87 percent) and medical school-associated (96 percent) hospitals. Hospitals in these categories train the next generation of clinicians and, in combination, serve over 50 percent of all Medicare beneficiaries. At the end of 2014, 67 percent of U.S. hospitals with more than 50 beds provide palliative care services, up from 15 percent in 1998 and 53 percent in 2006.
Exhibit 1
Meier-Exhibit 1
Source: America’s Care of Serious Illness 2015 State-By-State Report Card on Access to Palliative Care in Our Nation’s Hospitals.
The Bad News: Disparities In Access
Disparities in access to palliative care have persisted since these data were first tracked in 1998. As in other aspects of health care, where one lives matters. Hospitals (referred to in this report as those with more than 50 beds) in the East South Central (42 percent) and West South Central (43 percent) parts of the U.S. are markedly less likely to have a palliative care program as compared to New England (88 percent), Pacific (77 percent) and Mid-Atlantic (77 percent) states. Hospital ownership is also a strong predictor of access to palliative care. Not-for-profit (77 percent) and public (59 percent) hospitals are significantly more likely than for-profit (23 percent) hospitals to have palliative care programs.
Implications: Standardize Access
Given the evidence that palliative care improves value for the highest-risk highest-cost patients, efforts to improve and standardize access to it should be prioritized. Despite growth in the prevalence of hospital palliative care services over the last 20 years, it is important to note that the presence of a palliative care program in a hospital is not equivalent to actual receipt of palliative care by patients who can benefit.
Data on penetration (percent of patients who would benefit from palliative care who actually receive these services) are necessary to identify gaps and to standardize access to palliative care within hospitals. Barriers to receipt of palliative care by high-risk hospitalized patients include late or non-referral by primary treating physicians; clinician misunderstanding of the role and contributions of concurrent palliative care for patients who are not on the brink of death; understaffed palliative care teams; and lack of training of the U.S. health care workforce in the core principles and practices of palliative care (pain and symptom assessment and treatment, communication skills, and caregiver support).
Of even greater concern is the fact that reliable access to palliative care only exists in hospitals, and for those with limited life expectancy, through hospice. The majority of high-risk, high-cost, and seriously ill persons are neither hospitalized nor imminently dying, but living at home and in nursing homes. Closing gaps in access to palliative care in community settings is one of the single greatest opportunities to increase value in the U.S. health care system.
Next Steps
Strategies to improve timely access to quality palliative care for all who can benefit in all settings will require a series of policy levers, including the following:
new accreditation and regulatory requirements;
clinician training in core palliative care practices as a condition of board certification or recertification;
sustainable reimbursement for the activities of the interdisciplinary team; and,
targeted identification of at-risk populations.
Concomitantly, development, evaluation, and subsequent dissemination of new palliative care delivery models outside of hospitals and hospice programs need to be undertaken. These steps are necessary to ensure high value health care for the seriously ill.
By:Diane Meier and R. Sean Morrison
Source: http://healthaffairs.org/
{module[153]}