Feature

Joe Rotella, MD MBA HMDC FAAHPM, Chief Medical Officer, AAHPM

Community-based palliative care (CBPC) is one of the hottest trends in the field of hospice and palliative medicine. A question posted on AAHPM’s Connect Open Forum in December asking about interest in forming a special interest group (SIG) for outpatient palliative medicine received an overwhelming response; the new Outpatient Palliative Medicine SIG now hosts 174 members and an active discussion board and continues to grow. The original poster, Kim Curseen, MD, director of Supportive and Palliative Care Outpatient Services at Emory Healthcare, says, “I was hoping the community would provide a network for providers to support and educate each other, produce future thought leaders, further education and research, and serve as a platform for recruiting more providers into this professional track.”

In August, MJHS, a not-for-profit health system in New York, became the first organization in the nation to receive the Joint Commission’s Community-Based Palliative Care Certification, based on its compliance with requirements for a robust interdisciplinary care team, customized comprehensive care plans, after-hours care and services, use of evidence-based clinical practice guidelines, and a defined hand-off communications process.¹ Now many organizations are working to develop training courses and resource kits for leaders planning a CBPC program, including the MJHS Institute for Innovation in Palliative Care, which is developing a distance-learning program with funding from a foundation. Russell Portenoy, MD, executive director of the MJHS Institute for Innovation in Palliative Care and chief medical officer of MJHS Hospice and Palliative Care, has seen interest in CBPC take off. “Remarkably, the world is moving more quickly than we can develop education to support it,” he says.

What Is Community-Based Palliative Care?

CBPC refers to the provision of palliative care services outside of a hospice benefit or an inpatient hospital setting. The place of care may include a patient’s residence (eg, home, assisted living or nursing facility), a freestanding outpatient clinic, or a clinic embedded in a cancer center or other outpatient facility; some programs extend services to the homeless. In addition to traditional face-to-face visits with clinicians, some CBPC programs offer virtual visits using emerging telehealth technologies. Martha Twaddle, MD HMDC FACP FAAHPM, senior vice president of medical excellence and innovation for JourneyCare and senior medical director for Illinois and Indiana for Aspire Health, describes CBPC as a “patient-centered care delivery system” (see CBPC as Care Delivery System).

"Remarkably, the world is moving more quickly than we can develop education to support it."
– Russell Portenoy, MD, Chief Medical Officer, MJHS Hospice and Palliative Care; Executive Director, MJHS Institute for Innovation in Palliative Care; and Professor of Neurology and Family and Social Medicine, Albert Einstein College of Medicine

In the community setting, patients’ and families’ palliative care needs often overlap with the needs addressed by primary care and other specialty teams. Christine Ritchie, MD MSPH FACP FAAHPM, the Harris Fishbon Distinguished Professor in Clinical Translational Research and Aging at the University of California–San Francisco, suggests an approach of short-term specialty-level palliative care consultation bolstered by training in the basics of palliative care for the other providers who care for patients with serious illness (see Distinction Between Palliative and Primary Care in the Home).

Five Keys to Unlock Value

1. Know What Patients—and Healthcare Partners—Really Need

A rigorous needs assessment should be the first step in planning a CBPC program, encompassing not only what matters most for the specific patients in the care setting that is targeted but also the healthcare payers, systems, and other providers involved in their care. Unlike hospices, which have a well-defined, comprehensive payment and service model, CBPC programs have to focus on the essential services that will make the most difference and find a way to get paid for them. Lynn Spragens, MBA, president and CEO of healthcare consulting firm Spragens & Associates, recommends looking for pain points in the system. “Somebody needs you to fix something—who is it and what is their burning platform?” She suggests thinking of needs assessment as a strategy (see Needs Assessment as a Strategy). As more payers and systems take on risk in the form of Accountable Care Organizations (ACOs) and bundled payments, the triple aim of health care value—better outcomes for populations, better patient experience of care, and lower total costs—increasingly matters to them. They are motivated to avoid high-cost, low-benefit interventions, including preventable emergency department (ED) visits and hospitalizations, especially readmissions within 30 days. It pays to find the points of care where the needs of patients and payers most align and provide targeted interventions that make a difference. In describing the sweet spot for CBPC, Twaddle says "it's critical to identify people before they start the vortex of nonbeneficial utilization and create support such that they do not have to be hospitalized or go to the ED unless those are the best options and intentionally pursued."

CBPC as a Care Delivery System
Martha L. Twaddle, MD HMDC FACP FAAHPM
Senior Vice President, Medical Excellence & Innovation, JourneyCare
Associate Professor of Medicine, Northwestern University
Senior Medical Director, Aspire Health

“It is important to think about palliative care as not just a program or service but rather a delivery system of care for people living with serious and progressive illnesses and those who love and care for them. These folks need help with care management and ongoing support and advocacy that flexes nimbly to their needs in the setting where their care can be optimized. This is a very vulnerable population that is often invisible until care needs escalate beyond what a family or caregiver can support. They rely on a patchwork of fragmented services within the home setting that comes and goes despite often having illnesses that are relentless. There are naturally occurring access points where we meet people with serious illness, and the goal is to assess, screen, and trigger services such that they don’t have to suffer first to get our attention.”

Distinction Between Palliative and Primary Care in the Home
Christine Ritchie, MD MSPH FACP FAAHPM
Harris Fishbon Distinguished Professor in Clinical Translational Research and Aging
University of California–San Francisco

“Home-based palliative care and home-based primary care are intersecting Venn diagrams. Home-based primary care generally provides longitudinal primary care in the home. Given the frailty and physical limitations of this population, many have palliative care needs. Many homebound patients do not have access to specialty palliative care; therefore, promoting primary palliative care training and expertise among primary care providers caring for patients in the home is essential.”

2. Tailor the Service Model to What Matters Most

CBPC is not a one-size-fits-all proposition. Leaders are always exploring innovative models, and some programs offer a portfolio of CBPC services to fit the particular needs of patients and payers. Portenoy describes MJHS Hospice and Palliative Care, for example, as “a multifaceted CBPC program that complements a facility-based program and has been continually evolving since it started almost 10 years ago.” Its “high-touch model” is an openended, interdisciplinary service offering home visits by a physician or nurse practitioner and a social worker, chaplain visits by arrangement, telephonic outreach by a nurse, and access to on-call services, all funded through capitated contracts with a small number of managed care companies. MJHS also offers a brief consultation model, the Acute Palliative Care Initiative, that promises a maximum of a few home visits by a physician, nurse practitioner, and social worker bundled with access to on-call for a period of weeks to a few months, with the goals of managing care transitions, reviewing hospice eligibility, and developing a plan of care to convey to the primary physician. In contrast, the MJHS program that received the Joint Commission’s certification in CBPC is more of a generalist-level palliative care model based in home health. It includes patient screening, comprehensive assessment with repeated use of a validated multidimensional tool, protocols for interventions by home health nurses to address symptoms and advance care planning, direct access to a specialist social worker and chaplain, indirect access to an experienced palliative care physician by means of weekly interdisciplinary team meetings, and a training program for nurses.

Although CBPC programs differ in the range of services offered, how they are provided, how they are reimbursed, and for how long, there are essential components of care they have in common: addressing pain and symptoms, clarifying goals of care (including advance care planning), coordinating care (especially care transitions), and providing education and emotional support for patients and caregivers.

Needs Assessment as a Strategy
Lynn Spragens, MBS
President and CEO
Spragens & Associates

When planning a CBPC program, it’s important to be rigorous in understanding stakeholders and context so that your program design reflects organizational priorities and can be sustainable. Key questions include:

• What is the problem statement? Where are the gaps in care that you are trying to fill?
• Why do those gaps exist now?
• Who else is working on this? How can you collaborate or integrate with these initiatives?
• Who has the most at stake to solve these problems? What keeps them up at night?
• What baseline data will help illustrate the gaps and opportunities for improvement?
• What service characteristics will be most important?
• How will the people who can pay to support expanded services want to evaluate our impact?

Why Palliative Care Doesn't Fit a High-Volume Clinic Model
Kim Curseen, MD
Director of Supportive and Palliative Care Outpatient Services
Emory Healthcare

“It’s difficult to manage the finances of a traditional outpatient practice. The volume that primary care providers need to see to sustain their practices leads to scheduling 15 minutes for follow-up and 30 minutes for new patients. This is not feasible for a palliative care clinician who manages symptoms beyond physical pain. In my experience, patients are referred with high-level needs that cannot be managed in a typical brief primary care or specialty visit. Practices that are not subsidized (eg, by an academic center, ACO, or hospice), do not have endowments, and are not in a closed system like the Veteran’s Administration may have a difficult time. Just like palliative care in the hospital, CBPC requires an interdisciplinary team, including nonbillable providers who have to be factored into the cost.

3. Figure Out How to Get Paid

Experts agree that the biggest challenge to the long-term success of CBPC is securing the funding to support an effective program at a level that not only is sustainable but also allows room to grow. New programs require outside grants or initial capital investments from their host organizations to cover their start-up costs. Healthcare reform has unleashed a host of value-based payment models that can generate revenue to sustain CBPC programs. They are primarily built on five basic paradigms applied singly or in combination: fee-for-service (FFS), case rate (bundled payment), capitation, salaried employment, and shared savings. Traditional FFS reimbursement alone is insufficient to cover the ongoing costs of a robust interdisciplinary palliative care team and expanded services such as 24/7 on-call access and care coordination.

When billable visits contribute to program revenue, it is critical that clinician services are properly documented, coded, and billed. Janet Bull, MD MBA HMDC FAAHPM, chief medical officer of Four Seasons Compassion for Life, emphasizes the importance of understanding both complexity- and time-based coding as well as the use of new advance care planning codes. “Most clinicians don’t get this and leave a lot on the table,” she says. Curseen finds it tough to adapt palliative care to the traditional outpatient clinic model (see Why Palliative Care Doesn’t Fit a High-Volume Clinic Model). Some CBPC programs have negotiated with payers for a higher fee for billable services to cover the expanded nonbillable services provided. Some contracts with payers have structured the reimbursement as a bundled payment per case over an episode of care or defined time frame. Others operate on a capitated, per member per month (PMPM) basis. Under salaried employment models, the CBPC program may be allowed to operate at a loss as a cost center in return for other benefits (eg, more appropriate hospice referrals) or costs avoided in other centers (eg, decreased 30-day hospital readmissions). Negotiating for a share of savings is yet another option but it often comes with an expectation that the program also share risk.

New CBPC programs are rarely in a position to take on any risk beyond their operating costs, and it can be challenging to agree on a valid methodology for selecting patients and calculating the savings that can be attributed to the CBPC intervention. There are many hybrid models that combine two or more of these payment paradigms, for example, FFS billing for clinician visits plus a capitated PMPM payment to cover psychosocial support, care coordination, and on-call services.

Opportunities are emerging for developing new payment models for CBPC. Four Seasons Compassion for Life received a nearly $10 million grant from the Center for Medicare and Medicaid Innovation to test a new model for CBPC, in conjunction with Duke University.² The results of the project could strengthen the case for development of a Medicare/Medicaid benefit for CBPC. Under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), eligible clinicians are rewarded for participating in advanced alternative payment models (APMs). There is no APM currently approved for CBPC, but MACRA provides a mechanism for outside stakeholders to submit physician-focused payment models for consideration as APMs. In November, AAHPM convened members with payment and policy expertise to explore strategies to address the potential of APMs for the broad field of hospice and palliative medicine.

4. Know How YOu Will Show Value

Before launching a CBPC program, it’s important to determine what metrics will be gathered and reported on an ongoing basis to demonstrate its value. CBPC leaders are wise to measure what matters most to patients and to the payer funding the program. At Four Seasons Compassion for Life, Bull uses a variety of quality and utilization metrics. “We collect data through the Quality Data Collection Tool (QDACT), nine measures of which are part of a qualified clinical data registry (QCDR). We strive to understand the ‘win/win’ in a valuebased reimbursement system and track things like hospital readmissions, satisfaction surveys, costs, and reimbursement.” Positive results will support the sustainability and growth of CBPC services.

"We strive to understand the 'win/win' in a value-based reimbursement system and track things like hospital readmissions, satisfaction surveys, costs, and reimbursement."
–Janet Bull, MD MBA HMDC FAAHPM, Chief Medical Officer, Four Seasons Compassion for Life

For patients within her ACO, Dana Lustbader, MD FAAHPM, chair of the Department of Palliative Medicine at ProHEALTH Care, an Optum Company, and clinical professor of medicine at Hofstra Northwell School of Medicine, found that CBPC is associated with significant total cost savings and better utilization patterns (see How CBPC Delivered Value to an ACO³).

Ritchie sees gaps in available palliative care quality measures when applied in the home setting. “We do not have a lot of good metrics for home-based palliative care. Some metrics such as pain and symptom control and identification and clarification of treatment preferences are important regardless of setting, although expectations for outcomes would likely be different for homebound patients. Other metrics such as safety in the home, caregiver support and guidance, and attention to treatment burden are more unique to the home environment.” She points to a Health Affairs article she coauthored with Dr. Bruce Leff and others that provides recommendations for quality metrics in various domains of home-based palliative care.⁴

How CBPC Delivered Value to an ACO
Dana Lustbader, MD FAAHPM
Chair, Department of Palliative Medicine, ProHEALTH Care, and Optum Company
Clinical Professor of Medicine, Hofstra Northwell School of Medicine

A study by Dr. Dana Lustbader and colleagues recently published in the Journal of Palliative Medicine reported the results of a retrospective analysis of the impact of home-based palliative care on total cost of care and resource utilization for patients in a Medicare Shared Savings Program ACO.3 The total cost per patient during the final three months of life was $12,000 lower with home-based palliative care compared with usual care ($20,420 vs. $32,420), with significant cost reductions in both Medicare Part A and Part B. Hospital admissions were reduced by 34% in the last month of life. Hospice enrollment increased by 35%, and hospice median length of stay increased by 240%.

5. Plan for the Long term

CBPC programs typically start small and leverage existing resources. Perhaps a good-hearted person sees an unmet need and simply dives in. Long-term success, however, depends on scaling resources to what is really needed. Spragens warns, “Don’t expect to get paid differently until you have enough scale to actually meet someone's needs. Immediate access is key; don’t be unavailable or backlogged or lag in your response.” When CBPC is provided in a value-based rather than traditional FFS arrangement, old paradigms based on driving volume of visits no longer apply. Spragens says, “What matters is effectiveness, not efficiency.” She considers quick access to be a core competency and advises against filling up the schedule with routine follow-up visits.

Experts agree that challenges in recruiting and training the workforce to deliver CBPC may limit growth. Lustbader notes, “We are in a very competitive market in New York, where finding the skilled clinicians to provide high-quality palliative care is difficult.” Palliative care programs historically have had to grow incrementally, often stretching too thin before resources are added, so it’s important to agree on an incremental staffing plan at the outset.

Challenges and Opportunities

Unlocking CBPC’s potential as a solution for enhancing patient-centered care and improving value requires novel service and business models in partnership with healthcare payers and systems. Many pilots are underway, but comparative effectiveness research is lacking on which care components and payment schemes are most cost-effective. There are many challenges, especially around funding and sustainability, but when patients’ needs are addressed in community settings, the promise to prevent and relieve suffering is great. Twaddle sums it up: “Seeing people in their homes helps us build durable, dependable systems of care to support people where they live as opposed to just where we go to work.”

References

1. The Joint Commission awards first Community-Based Palliative Care Certification to MJHS [press release]. Oakbrook Terrace, IL: The Joint Commission; August 18, 2016. https://www.jointcommission.org/joint_commission_ awards_first_community-based_palliative_care_certification. Accessed September 30, 2016.
2. Centers for Medicare and Medicaid Services. Healthcare Innovation Awards Round Two: North Carolina. https:// innovation.cms.gov/initiatives/Health-Care-Innovation- Awards-Round-Two/North-Carolina.html. Updated September 21, 2016. Accessed September 30, 2016.
3. Lustbader D, Mudra M, Romano C, et al. The impact of a home-based palliative care program in an accountable care organization [published online ahead of print August 30, 2016]. J Palliat Med. doi:10.1089/jpm.2016.0265.
4. Leff B, Carlson CM, Saliba D, Ritchie C. The invisible homebound: setting quality-of-care standards for homebased primary and palliative care. Health Aff. 2015;34(1):21- 29. doi: 10.1377/hlthaff.2014.1008.

Joe Rotella, MD MBA HMDC FAAHPM, is chief medical officer of the American Academy of Hospice and Palliative Medicine, Chicago, IL, and president and founder of CatalystHPM, Louisville, KY. He can be contacted at This email address is being protected from spambots. You need JavaScript enabled to view it. .

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