More patients than ever are seeking hospice and palliative care, and the industry may not have enough trained clinicians to take care of them. To help fill this gap, Rep. Eliot L. Engel (D-NY) and 285 bipartisan co-sponsors have reintroduced the Palliative Care and Hospice Education and Training Act (H.R. 647) in the House of Representatives.
The bill would provide funds to increase the number of permanent faculty in academic institutions that train hospice and palliative care providers, with the ultimate goal of growing the workforce. Other provisions would create a national campaign to promote the benefits of palliative and hospice care among health care providers and the public, and would expand National Institutes of Health research efforts on hospice care.
“Students graduating from medical, nursing and other health professional schools today have very little, if any, training in the core precepts of pain and symptom management, advance care planning, communication skills, and care coordination for patients with serious illness, and there is a documented shortage of palliative care specialists,” Engel told Hospice News. “The legislation aims to build a health care workforce more closely aligned with the nation’s evolving health care needs.”
Currently the United States has 13.35 hospice and palliative care specialists for every 100,000 adults 65 and older. An April 2018 study estimated that by 2040 the patient population will need 10,640 to 24,000 specialists; supply is expected to range between 8,100 and 19,000.
Hospice and palliative care providers are already seeing shortages in other disciplines, including chaplains, nurses, and social workers. As far back as 2008, the U.S. Centers for Medicare & Medicaid Service (CMS) began allowing hospice providers to use contracted nursing staff because not enough nurses were available to fill permanent positions.
In 2015 only 44% of hospital palliative care programs met national staffing standards set by The Joint Commission. The shortages are exacerbated when considering the current rapid expansion of community-based palliative care, such as in outpatient and home-based settings.
“There are many hospices across the country that are having very serious challenges recruiting and retaining physicians, nurses, and other staff,” said Stacie Levine, M.D., section chief of Geriatrics and Palliative Medicine at the University of Chicago Medical Center. “We have the baby boomers reaching their twilight years, and I am not sure what we are going to be able to do with what we have in front of us.”
Clinicians need advanced training in order to provide effective hospice and palliative care. Even the best educated physician or nurse can’t graduate from their program and immediately step into that role.
“We know that a fresh graduate is going to need significant support for at least three months if not longer to make sure we are comfortable that they can provide a good comprehensive palliative medicine assessment, and for them to be comfortable holding family meetings, discussing goals of care, and the more emotional aspects of this job,” Levine told Hospice News.
Funding for training will not solve the problem entirely, but it can make a significant difference. Many hospice and palliative care training programs rely on philanthropy, donations, grants, and fundraising to finance their activities.
Industry observers are encouraged that the pending legislation takes a multifaceted approach, such as the establishment of specialized educational centers, “train-the-trainer” programs, and accounting for different levels of training, such as basic palliative care principles, specialist training, and more intense training for professionals seeking to enhance their skills.
These approaches have produced positive results in other disciplines facing shortages, such as geriatrics. However, some feel that the entire model for palliative and hospice provider training needs to change to accelerate the entry of new professionals into the workforce.
“I think that the traditional model is not going to work where everybody is going to have to go back and do a fellowship,” said Lauren Weibe, M.D., oncologist and hospice and palliative care physician at NorthShore University Health System. “Because it has to be somewhat on the job, concurrent with everything else those providers are doing, and that’s going to take time and financial support to make sure it is done well.”
An earlier version of the bill passed the House in 2018 but did not come to a vote in the Senate. Rep. Engel told Hospice News that he is optimistic that the current Congress will enact the legislation, which more than 50 hospice, palliative care, and health care industry organizations have endorsed.
Paying for training is an important first step to address an issue that many think requires a re-evaluation of how care is provided and paid for.
“Good doctoring is being replaced by efficient doctoring,” Weibe said. “Palliative and hospice care needs to explore the patient’s priorities and decisions. Often we are seeing patients on the worst day of their lives, and they need us. These things cannot be rushed. It’s not financially feasible from a reimbursement standpoint to even continue the model. There needs to be a higher level discussion to make sure hospice and palliative care is supported and sustainable.”
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