Janell Solomon, director of compliance at Pueblo, Colo.-based hospice and palliative care provider Sangre de Cristo Community Care, executes and monitors ever-changing laws, regulations, policies and industry standards. Hospice News recently spoke with Solomon about the ways palliative care is evolving and expanding in the United States and the challenge of ensuring financial sustainability absent a dedicated payment model that covers the full range of interdisciplinary services.
What are some of the factors that are driving the rising interest in palliative care?
Across the nation, we are seeing changes in the health care continuum about not only what kind of care patients need, but also where those patient’s comfort levels are and where they’re seeking out that care. That has a lot to do with why we’re seeing changes in palliative care.
We’re also seeing a tremendous uptick of people understanding the difference between home health and hospice and palliative care — that they really are different types of care that can be provided and sometimes their tendrils intermix with each other. Sometimes they each have their own very unique need and niche to serve those patients out there. And so often, not only from a cost perspective, but just from a comfortability perspective, many patients don’t want to be in an acute care setting or in a hospital setting or even structured doctor’s office setting any longer.
What do you see on the horizon in terms of the payment landscape for palliative care?
I’d love to say that I see a really positive improvement, but I don’t quite have that comfort level. I do see different pay sources as well as Medicare and Medicaid talking about changes in payment for these types of services.
Of course, until we see final rules and actual payment amount postings, I think we’re still in a little bit of the unknown, because palliative care is still something we can get paid for. There’s not a whole lot of truly financially successful palliative care programs that are able to stand alone without the backing of a hospice or a hospital or a home health system.
Do you think that the pandemic has affected the trajectory of palliative care in terms of growth?
I actually think that the pandemic has opened our eyes to needs for different types of care outside of a structured acute care and physician office settings. The definition of palliative care has really been expanded in a lot of people’s mindsets, because they understand the need for a different type of care. I think they also understand that the pandemic has opened our eyes to truly understanding patient wishes, and meeting our patients where they’re at to give them the right kind of care for their symptom management or for what they need at that time.
Do you think we can start to ensure greater access to palliative care going forward?
I think we need to ensure that we have structured palliative care programs that are able to provide data. That’s how we not only get more and more people in our communities aware of palliative care, but also the other providers. When we think about the payment question we talked about earlier, really understanding why we need palliative care needs to be driven by tried and true data to get more and more backing behind that.
Data are really needed to be able to prove the benefits of palliative care. How does it decrease hospitalization? How does it improve patients’ quality of life and satisfaction with their symptoms? Really being able to have that data proven information will help all of us in palliative care.
Can you talk about some of the things that providers need to keep in mind in terms of compliance when they add on a new clinical service like palliative care?
As far as compliance, we don’t have structured palliative care components like we do and say hospice or home health. We don’t have those star ratings that you see for those other things. Compliance in palliative care is really driven by the rules of health care, the rules of patient care, ensuring that we are compliant with patient wishes, with the drug regimens such as medication review — especially in the current opioid epidemic.
A lot of people think about palliative care, and they think about pain management. That’s not all that palliative care is, but a lot of times it can be a big portion of it. So compliance related to accurate drug medication reviews, accurate records and medication profiles are key in the palliative care world.
We also need to make sure that we’re aware of the patient’s advanced care planning needs, and that we have compliant and accurate records to prove we have had those conversations, have the documents in place, and communicate with other providers that are involved in that patient’s care.
Could you tell me about your organization’s palliative care program and what kind of payment arrangements you make to sustain it>
Our palliative care program here at Sangre de Cristo is a part of our agency as a whole. To say it’s completely standalone and successful is kind of a month-to-month basis. We are very successful in growing our palliative care program month over month and in increasing our ability to bill for those palliative care services.
Sometimes there’s just so much out there that needs to be done for these patients that we can’t bill for, so that’s a little challenging. We are always looking for new avenues to make our palliative care program financially sustainable by itself. Remote patient monitoring and telehealth services have helped during the pandemic and represent new ways that we can ensure we have those streams of income coming in to support palliative care.
Advanced care planning is something that palliative care providers do really well. Of course, we can only bill for the initial time. If someone else has already had that, then our team is still coming in and sometimes helping provide those services when we’re not able to bill for them. But it is the right thing to do for the patient and the community.
Sometimes patients’ requests or their advanced care planning needs change over time as their health changes. Right now there’s no mandate or any financial payment alleviation if a patient has changes to their needs for advanced care planning. We currently successfully bill and have contracts with multiple private insurance companies as well as Medicare and Medicaid, when the services are appropriate to bill for palliative care
If you were to write a prescription for palliative care growth, what advice would you have for other providers?
First and foremost, this is something our own agency went through. I’ve been here for 10-and-a-half years. I’ve seen the evolution of our palliative care program over that time, through a couple of different mindsets. I think the most important first step is to figure out what your agency’s palliative care program goal is. Is it about making money and being financially sustainable? Is it about serving a community even when it might not be financially sustainable? Is it about this psychosocial side of palliative care, or is the true clinical symptom management?
Once you decide as an agency what your focus is going to be, you want to make sure that your entire agency, as well as the other providers in your area, truly understand your program criteria. We have a palliative care program criteria that we have updated pretty recently. It talks about what our team can do to help a palliative care patient manage symptoms with a cancer diagnosis, or any one of the following diagnoses as with symptoms, like pain, nausea, vomiting, anxiety, agitation, shortness of breath, or fatigue.
Those symptoms are related to their palliative care diagnosis, and it requires regular maintenance and a prognosis of less than two years.Then we list out the various palliative care diagnoses. We talk about patients that have advanced illness with active decline, such as ER visits or hospitalizations in the last six months or a decline in their ability to perform activities of daily living. They might have had nutritional decline and weight loss in the past three months. We really felt like this document helps solidify for our whole agency what we are trying to do and the boundaries of what we are going to do.
We talked about how our palliative care program is going to do navigation assistance with community resources, potentially helping people get their hands on the right Medicaid application, getting transportation resources to doctor’s appointments, coordinating with other providers, and really help patients create that roadmap for their care.
Basically, palliative care provides an extra layer of coverage and peace of mind for the stresses that come with a serious, life-limiting illness. It’s a customized care plan that’s created with a team of doctors, nurses, social workers, and other specialists who work with that patient and their care team to provide relief from symptoms, pain, and stress of serious illness.
The No. 1 thing I can say to other agencies that are looking at palliative care is: Define your palliative care mission, not only to your own agency, but to the providers in your community that you’re going to be working with, as well as to the community itself.
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