Transferring seriously ill patients to a different care setting at the right time may be the greatest prescription a provider can offer them.
When patients are dealing with serious illness, determining when to prescribe palliative or hospice care can seem like an unfair ask. Physicians are trained to treat patients and give them hope — to keep them healthy and alive through every medical intervention available. However, transferring seriously ill patients to a different care setting at the right time may be the greatest prescription a provider can offer them.
Palliative medicine and hospice care ensure the highest level of medical, emotional, spiritual, and financial support possible for the time patients have left and may give patients the chance for a longer life than medical professionals might predict. Additionally, in an era when care costs are accelerating, and value-based care (VBC) contracts require providers to minimize unnecessary treatment, palliative and hospice care can decrease acute care utilization and maximize the use of well-needed primary care services. It may even help organizations secure the bonus payments VBC promises.
But how do providers know which service to refer to and when?
First, it is critical to understand the difference between the two disciplines. Once a provider has a good sense of what care to prescribe, advanced data analytics and technology can serve as a guide.
Palliative medicine: Critical at every stage of illness
While hospice eligibility requires a six month or less life expectancy diagnosis, palliative medicine is not driven by life expectancy. As a palliative medicine specialist, my job is to relieve the burden of suffering at any stage of an advanced illness. Because of our deep experience in managing interventions for this patient population, palliative providers often provide pain relief and treatments unfamiliar to non-palliative providers. Additionally, we focus on improving quality of life with the medical, emotional, spiritual, and financial support patients need to achieve comfort and a sense of peace and meaningfulness in the time they have left, whether that is years, months, or weeks.
Research in the advanced lung cancer population has demonstrated that palliative care introduced early after diagnosis results in a lower symptom burden, 50% less depression, and extended life compared with standard oncology care. As we move into a future where palliative medicine is widely recognized as a specialty that can improve outcomes, it should be adopted as a paradigm of care that is integral to advanced disease management.
Hospice care is designed specifically for end-of-life
Hospice eligibility is based on the prediction that the patient has six months or less to live. The focus of care is on comfort, and patients forego life-prolonging interventions. In addition to medical, emotional, spiritual, and financial care and counseling, patients in hospice benefit from full coverage for medical equipment and supplies; physical, occupational, and speech therapy services; respite care for caregivers; and grief and loss counseling for their families.
Technology helps determine when patients are ready for a new level of care
Generally, physicians have had to rely on personal judgement and experience to decide when a patient is ready for a different level of care. They might look for frequent hospitalizations, significant weight loss, increasing pain, or recurring infections that signal the end is near. Prognostication remains an inexact science. At times, providers may have a patient who is ready to stop treatment and requests hospice.
Today, with advances in data analytics combined with machine learning and artificial intelligence, doctors don’t have to wait for the most obvious signs of decline to offer patients access to the benefits palliative medicine and hospice care provide.
New analytics tools are already available to aggregate a patient’s complete medical, social, and emotional profile using multiple sources of data. It is now possible to identify whether the patient is in or is entering a high utilization period that affects quality of life. Such technology can prognosticate with incredible accuracy when a patient has months left to live, providing vital support for what historically has required educated guessing.
Using the data in an EHR, however, may not be sufficient. A single EHR rarely captures the full extent of seriously ill patients’ conditions. Doctors can’t know all the providers and facilities—past and present—involved in the patient’s care. They can’t know which patients are at risk of high acute utilization and need intervention now. They can’t know exactly when to transition patients to palliative or hospice care or track the quality metrics that help determine the best referrals possible.
CMS is now piloting a program called Data at the Point of Care (DPC) that provides three years or more of data on any patient providers have submitted a CMS claim on (Part A or Part B). This data can be integrated with EHRs and used to develop meaningful insights, including Palliative Performance Scale and mortality risk scores that enhance clinical decision making.
As providers gain access to tools like DPC, it will become much easier to determine patients’ readiness and qualification for palliative and hospice care. Combining technology with a better understanding of these critical services will improve physicians’ confidence in making a referral that will enhance advanced care management and maximize resource utilization in a way that benefits patients and the healthcare system alike.
John Mulder MD, FAAHPM, HMDC, is a hospice and palliative medicine specialist with more than 30 years of experience. He is the chief medical consultant for hospice and palliative care at Holland Home, one of the largest provider of elder care services in Michigan, the director of the Division of Palliative Medicine at Michigan State University College of Human Medicine, and a member of the Board of Directors for Acclivity Health, a technology innovator in transforming care for the seriously ill. acclivityhealth.com