The Organizational Case for Palliative Care

Leaders at Baylor Scott & White Health have developed a program to lower costs, improve quality, and reduce readmissions.

This article appears in the July/August 2015 issue of HealthLeaders magazine.

It wasn't that long ago that the healthcare payment system was structured against palliative care, recalls Robert Fine, MD, FACP, FAAHPM, clinical director of the Office of Clinical Ethics and Palliative Care at Baylor Scott & White Health. An effective family meeting or "goals of care discussion"—where the physician sits down with the patient and his or her family and discusses patient pain and family needs—takes at least 90 minutes, more than six times the norm of the typical office or hospital 15-minute physician visit.

"Well, there's not even a code for family meeting, right?" Fine says. "I used to kid our administrators. I showed them some of our data on reduced readmissions and shorter length of stay. I said, 'If you're getting paid for every one of those days, I'm your enemy because I'm shortening length of stay.' So you had to have this shift in how healthcare's reimbursed for hospital administrators to go, 'Oh, I get it.' "

Changes in reimbursement through healthcare reform, as well as the general marketplace mandate for more efficient and cost-effective care, have finally altered that equation. So has the view of palliative care from the administrative side, says Fine.

"If it's a value-based payment mechanism, I'm your friend. If you're getting penalized for readmissions or length of stay, then suddenly the time it takes to do the better care planning, or the extra staff it takes to work with the children, or the better pain management we do in the clinic, now we fit that value equation. That's what Baylor Scott & White leadership has really understood."

As the payment system has evolved, so too has the palliative care team at Baylor. From serving 119 patients in the first nine months of the program in 2004, the supportive and palliative care team (SPC) provided 4,192 new inpatient consults, 11,098 hospital follow-up visits, and 748 outpatient office visits in fiscal year 2014. From a part-time team on a single campus, the Baylor Scott & White SPC team now has eight physicians, 10 advanced practice nurses, one registered nurse, six social workers, five certified child life specialists, and five spiritual care providers spread across north and central Texas, and the team will grow by six members in the coming years.

The team has grown because results have supported its value to the system, says Martha Philastre, MS, MBA, FACHE, administrative director of palliative care, who works with Fine in dyad leadership for the program. "One metric that we are definitely showing a reduction in is readmissions," Philastre says. "We have demonstrated a 17% reduction if a patient is seen by palliative care as opposed to a matched patient that didn't get palliative care."

The greatest cost savings come when the SPC team is engaged early in the hospital stay, Philastre says. Baylor's healthcare economist conducted a study in 2013 that tracked 2,405 SPC consults over a 42-month period and compared them with a control group. In that study, the SPC team demonstrated cost savings of $9,128 per patient for the first five days of hospital stay and $9,699 from days 6 to 10 for patients who died. For patients who were discharged, the savings were $2,667 for the first five days of a hospital stay and $2,743 for days 6–10.

"If we see a patient within the first 10 days of them being in the hospital," Philastre says, "we will show significant cost savings as opposed to a patient that has been in the hospital for over two weeks because typically, by that time, so much cost has gone into the patient that may or may not have needed to happen, that it's sort of done by that point."

Fine is quick to point out that only one in five of patients seen by the SPC team die in the hospital, which means the other four go home or are discharged to skilled nursing or hospice. Along with the shift in the payment model, there has been a change in the perception that palliative care is only for patients who are in the last stages of dying, Fine says. One of his best examples of the value of palliative care came from a Baylor staff nurse named Amy who was battling colon cancer.

"Amy gets admitted by her oncologist after she's already had surgery and treatment. She is in horrible pain. I happen to be on call the evening she's admitted. I go to meet her. It was very apparent that she was afraid that she was dying, and that I was from hospice. And I said, 'Let me just reassure you, I'm not from hospice. I'm from the supportive and palliative care team, and my job, first off, is to palliate. That means to comfort you, to make your pain go away. And my second job is to support you and your family. I want to make you feel better so that you don't have to be in the hospital, so you can get up out of bed and continue to take your treatment.'

"She was so relieved. The next day, her pain was so much better and she was emotionally relieved. She said more people need to know about this. She asked, 'Why wasn't I referred to you six months ago? Why have I kind of mucked around in pain for all these months?' "

Fine says there are three reasons for consults: care planning, pain, and other symptom management. "Many patients need help with all three, but care planning is the single most common reason we get called, and that is also why we need more time to work with patient and family."

Cancer patients make up 32% of patients, followed by cardiac at 15% and neurology at 13%. Fine says the focus on using pain management in palliative care is for serious illness. "We get a lot of consults for pain. We emphasize to people that we don't do chronic pain management, like chronic back pain. We don't do routine postop pain management, but for a cancer patient with pain, we get called all the time."

The SPC team set a system goal of having at least 80% of its patients report that their pain was better after SPC pain management stepped in. In the two years studied, the number of patients reporting better pain management was consistently above 85%; some months it climbed to above 90%.

Reprint HLR0815-11

This article appears in the July/August 2015 issue of HealthLeaders magazine.