Five hospitals are the first in the nation to receive The Joint Commission's advanced certification for palliative care, a six-month-old program that the agency's David Eickemeyer says "has taken off faster than any other advanced certification program we've ever introduced, including stroke."
The Joint Commission does not have a "regular" palliative care certification. It chose to call this "advanced" certification to distinguish these programs from hospitals that simply say they have palliative care programs.
To earn the distinction, hospitals must be Joint Commission-accredited and must demonstrate these key capabilities:
- Provide a full range of palliative care services to hospitalized patients 24 hours a day, 7 days a week, with team members available to answer phone calls nights and weekends, and be able to see patients in the hospital whenever necessary to meet patient and family needs.
- Have already served at least 10 patients and had one active patient in palliative care when it received its on-site review from the Joint Commission.
- Have the ability to direct clinical management of patients and coordinate care, such as write orders, direct or coordinate activities of the patient care team, and influence composition of the patient care team.
- Use a standardized method of delivering clinical care based on clinical practice guidelines or evidence-based practice
- Use performance measurements and have at least four months of measurement data at the time of the first on-site review.
- Have a licensed interdisciplinary program team consisting of a licensed independent practitioner, registered nurse, chaplain and social worker.
- Depending on the needs of the population served, they utilize expertise of individuals from child life services, clinical pharmacy, gerontology, nutrition, pediatrics, psychology and rehabilitative services.
The hospitals named as the first five are
- Regions Hospital in St. Paul, MN;
- Strong Memorial Hospital in Rochester, NY;
- Mt. Sinai Medical Center, NY;
- St. Joseph Mercy Oakland, Pontiac, MI;
- The Connecticut Hospice Inc. in Branford, CT
Palliative care as a field of expertise is frequently misunderstood and misdefined by providers as well as patients. It is not only for the terminally ill, although many patients who receive palliative care may eventually go on to need hospice care services, Eickemeyer says.
Rather, palliative care brings in experts to coordinate care for patients with multiple diagnoses to relieve their pain, suffering, anxiety, nausea, depression or stress, help them navigate the complex healthcare system and coordinate their care teams, regardless of how much longer they have to live.
Professionals help family members and patients to prioritize needs and to assure that patients get the right care at the right time. In many cases, such programs have allowed the patient to be discharged sooner than he or she otherwise would.
Only about 5% of hospitalized patients would qualify for palliative care services in most facilities. One study of patients with lung cancer found that palliative care programs actually helped them live longer.
Eickemeyer, associate director for The Joint Commission's certification program, says that for some hospitals, making allowances for such a program may seem too far a leap. "Internal financing can be an obstacle," because there is no billing code for palliative care at present. "How much is the leadership willing to support this when it's not a money making idea for the hospital."
He gives this example of the type of patient who would benefit with palliative care in a hospital with advanced certification. "A patient with multiple co-morbidities is admitted on a Friday, but on Saturday, the family comes for a visit.
"After visiting hours, the floor nurse finds the patient in obvious emotional distress (for no apparent reason). An advanced palliative care team would know what to do, would ask the right questions: Is this patient in need of pain medication or upset because of something that came up with the family. The advanced program can assess the person any time of day or night to get the right resources."
Sean Morrison, MD, director of the National Palliative Care Research Center and a director of the Hertzberg Palliative Care Institute at the now certified Mt. Sinai, said that over the past 11 years, "we've seen a dramatic increase in the number of hospitals that say they have palliative care teams," from almost none to 63% of all hospitals and 80% of hospitals with 300 beds or larger.
"But until the Joint Commission's advanced certification program, there were no quality metrics or quality standards that were uniform across the board that would allow patients and their families to say, 'Aha, this hospital has a high quality palliative care team.' "
Even though many hospitals say they have palliative care programs, what they have often falls far short because resources and expertise are either not available or not available all the time, he says.
3 Challenges to Palliative Care Programs
Palliative care programs that meet tough standards have been hard to develop for three reasons, Morrison says.
First: "There's still a misperception by hospitals (leaders) that palliative care is about end of life care, and that like the public, they need to understand and we need to better educate that there's a better way to take care of people with serious illness."
Second: "It's not a revenue-generating program." Under fee for service payment models, if there is not an operation or procedure, "it doesn't fit well within the hospital's model." That will probably change as accountable care organizations and other payment models emerge under the Affordable Care Act.
Third: There aren't enough people trained in palliative care or board certified in geriatric medicine. "It's a new specialty and there are simply not enough trained (palliative) physicians and nurses right now to fill the need. We really need some specific federal policies to promote the workforce issue."
Morrison says that although he is pleased that the Joint Commission has offered this certification and is pleased that his hospital was one of the first five selected, he doesn't think it should be voluntary but, instead, it should be "a key component of hospital accreditation," a necessary ingredient for federal reimbursement.
"You can't call yourself a hospital in the United States without an intensive care unit ...or unless you have an emergency department. I don't think you should be able to call yourself a hospital in this country unless you have a palliative care team."
Eickemeyer says that may come in time, but that this is a first step. Also, he says, some years down the line advanced certification may also mean hospitals will be expected to measure and improve on certain quality metrics associated with palliative care.
Most of all, by calling attention to the need for palliative care services with an certification program, Eickemeyer says The Joint Commission "hopes to attract resources and attention that might not otherwise materialize" for this area of healthcare.
About 20 other hospitals are moving through the application process and, within a year or two, he expects as many as 40 or 50 hospitals will earn advanced certification in palliative care.