With limited means of palliative care reimbursement, providers have had to develop creative approaches to their staffing models.

Some of those employers have folded wages for palliative care staff into the budgets of their hospice programs, for example. Others have designed a “pay as you go” model as they build out their palliative care businesses.

The absence of a robust palliative care reimbursement and regulatory structure comes with both benefits and challenges when it comes to care delivery and workforce management, according to Rebecca Doleman, vice president of population health at Heart to Heart Hospice.

“The lack of clearly defined guidelines and very specific expectations and boxes to check in the way that we’re familiar with in other health care delivery systems doesn’t exist in palliative care,” Doleman said during the Hospice News Palliative Care Conference in Washington D.C. “You’ve got to be willing to stand in that undefined space and work with whoever’s at the table in your area of influence to identify the gaps and come together in a collaborative relationship where you can provide the palliative care that supports and meets the needs of the partners at the table.”

A tale of two approaches to palliative care staffing

Dallas-Fort Worth-based Heart to Heart Hospice provides care through 51 locations in Texas, Michigan and Indiana.

Doleman is spearheading program design for Heart to Heart’s palliative care arm, InHome Connects. The palliative care provider is piloting a per member, per month payer model in its Texas markets, but otherwise relies primarily on a fee-for-service model and partnerships with payers in markets where it has existing hospice operations.

Operating within this structure has enabled Heart to Heart to sustain an interdisciplinary care model that blends hospice and palliative care, Doleman said. However, balancing wages and salaries against the payment constraints can be tough to manage, she added.

“We don’t break even, not on the palliative side where we find some counterbalance in sharing the responsibility of hospice face-to-face visits with our hospice program,” Doleman said. “That offsets some of the cost of clinician salary, and takes the burden off of a higher palliative census and the complexity of a palliative patient. Financially it makes sense, and it counterbalances some of the costs there. But it also brings a little bit of balance to the clinician’s caseload when it’s not a 100% palliative census that they’re managing. Outside of that, they’re salaried full-time.”

Operating in a blended hospice and palliative care model can be beneficial for recruitment, she added.

Hospice clinicians have the mindset, understanding and experience in delivering care to seriously ill patients and families during vulnerable stages in life, with skills that can translate well on the palliative side, Doleman said.

These are also important retention keys in finding the right clinicians for the right types of care delivery who have the “underlying motivation” for longevity and growth in the palliative field, she told Palliative Care News.

The biggest challenge in funding a palliative care workforce is communicating to payers what services should be included in reimbursement, Doleman stated.

A pay-for-visit system

Retention of clinical staff can be a large hurdle in the fee-for-service system, according to PalliCare, Inc. CEO Jonathan Fluhart.

Being a palliative provider that isn’t tied to a hospice, physician group or managed care organization allows PalliCare to operate across multiple care delivery systems, he stated. This provides the flexibility to “play with everybody in town” when it comes to working with other providers on collaborative payment, which can help fuel the ability to support patients and staff, Fluhart explained.

“Everybody” includes PalliCare partnerships with skilled nursing facilities, hospices, home health providers and facility- and community-based physicians who work with Accountable Care Organizations (ACOs).

Palliative can help fill gaps in care for seriously ill patients in home and facility-based settings who are not quite eligible for hospice, with cost savings and quality metrics that matter to ACOs and other stakeholders when demonstrating the value proposition of these services to payers, Fluhart said.

“We think of it as the Wild West — it’s undefined. The trail is there to be blazed,” Fluhart told Palliative Care News. “Being an independent [palliative care company], we have to eat our own dog food. I would love to have some kind of salaried nurses. I think salaried nurses have a lot of benefit, because you have a lot more coverage and things that you don’t get when you’re dealing with pay-per-visit nurses. But they’re expensive, and that’s a big part of what we’re trying to balance is the cost of the care and the delivery.”

The community-based palliative care company launched in 2021 and is headquartered in northeast Texas. It also has a small footprint in the Hudson River Valley area of New York state.

In PalliCare’s model, clinical staff receive a portion of the payment for services rendered during each patient visit. This means that pay for some of its workforce can be a slow build as clinical staff onboard, train and gain experience in care delivery. This can sometimes be a pain point that contributes to turnover, Fluhart explained.

“As far as retention, it takes time to onboard them [and] it takes more effort on our part to get them prepared to see the patients,” Fluhart said. “And when a lot of them work pay-per-visit, then they’re not making money until they see a patient. So we’re having to get them prepared, but at the same time they aren’t earning money. It’s very difficult to hold them until they’re ready to see patients.”