While providers and payers do what they can to scale palliative care, ultimately, payment reform will be “critical,” according to Dr. Glen Digwood, division chief of palliative care at Geisinger’s Wyoming Valley Medical Center.
Geisinger is a nationally recognized health system headquartered in Danville, Pennsylvania, that currently serves more than 1 million people in its home state. The system includes nearly 1,700 physicians, 10 hospital campuses, two research centers, a medical school, a health plan with more than half a million members, numerous clinics, outpatient facilities and home-based services. Just last week, the company announced that it would be acquired by a new Kaiser Permanente venture, Risant Health.
Palliative Care News spoke with Digwood about the company’s growth and how it’s been investing more time, money and energy into its palliative care services.
Geisinger is a huge organization. Can you describe some of the ways you offer palliative care or foster growth in those programs, be it through joint ventures, inpatient programs or outpatient and home-based services?
You are right, Geisinger is a large organization with many moving parts.
Palliative services are offered in a few different settings. We have traditional inpatient consultative services at four of our system hospitals. Additionally, at each of these four sites, we have outpatient palliative services embedded at cancer centers on these campuses.
For the remainder of our hospital campuses, we offer inpatient palliative consultation through telehealth technologies. Palliative medicine clinicians participate in a variety of multidisciplinary clinics at these sites as well.
How does palliative care factor into your health plan? What is covered and who is eligible?
On the health plan side, our robust Geisinger-at-Home program offers specialty-level palliative medicine home-based services.
This cohort of our members is identified by risk and care is made easy for them by being able to be seen and monitored at home. We partner with, depending on the geographic region, various community agencies to provide services.
What is Geisinger’s approach to palliative education in its medical school?
The approach is a slow build over time. Students are exposed to the concepts of palliation and hospice in the second half of their first year and longitudinally across the third and fourth years. We are a pilot site for the Aquifer Excellence in Palliative Care case set. In the clinical years, they are offered two-week palliative care electives in the third year or a four-week elective in the fourth year.
Additionally, a required four-week Health Systems elective can be fulfilled by choosing palliative medicine.
Combined, all these offerings set up our students to have sound competencies in skills such as communication, advance care planning and symptom management. The goal is for students to have a solid set of primary palliative care skills by the time they enter their residencies.
What is the impetus behind Geisinger’s commitment to palliative care?
This, I believe, stems from Geisinger’s century-long commitment to the highest quality care for our patients, their loved ones and our communities.
Our goal is to manage our patients’ total health and the cohort of patients we see in different palliative care environments are those with some of the most complex needs. Supporting them and their loved ones perfectly aligns with our values.
What are the biggest headwinds or limitations when it comes to your palliative care growth? How are you mitigating those?
We share many of the same challenges facing colleagues across the country.
Being good stewards of our resources in these times of financial challenges within health care, we continually communicate between leadership and clinical teams about what is working and what isn’t. We describe where the potential opportunities lie and how we can collaborate better to capitalize on them.
Recruiting in the world of palliative specialist shortage, Geisinger is truly a special place to work with the best benefits and endless opportunities for the motivated and curious clinician. But there are not enough hospice and palliative medicine specialists available to recruit.
Geisinger also fully embraces the role of advanced practitioners within palliative care and growing the [advanced practice providers (APPs)] to become qualified care providers.
Right-sizing teams and solving “the denominator challenge” of having the correct patients being seen, in the right setting, at the right time.
On the home side, operating in many rural areas, windshield time is an obvious challenge. This is mitigated by utilizing various technological capabilities.
What are you seeing in terms of cost savings from palliative care? Are those services reducing high-acuity utilization or hospitalizations?
We have published data on the impact our services have specifically on aggressive care at the end-of-life (ACEOL) indicators.
As one example, when we meet patients greater than 90 days prior to their death, we were able to reduce chemotherapy given in the last 30 days of life.
These are the types of data points that we continue to search for. They highlight the need to get further upstream in the right patient populations.
Our organization is always striving for operational excellence and identifying the patients we can serve best (those with the highest needs) is our mission. We, like everyone else in the palliative medicine space, continue to chase the need-based identification of patients.
We also create a lot of efficiencies for colleagues with different specialties here. Managing symptoms of those with various advanced illnesses provides optimal, high-quality care for patients. Most importantly, it frees up time for referring teams to see more patients and provide the medical management in which they are most expert.
What is coming next for palliative care at Geisinger in terms of how you will grow your programs or build payer/provider relationships?
Given our payer/provider structure, we are well-positioned for continued integration and growth.
We have followed the maturation pattern of most programs, starting in the inpatient environment, and subsequently developing outpatient clinics and in-home services.
The future will see development in all these arenas. Through outreach and relationship building, we have started partnerships with multidisciplinary clinics, most recently our ALS Clinic as just one example of outpatient changes.
We are also building out programs in the long-term care environment in collaboration with our robust SNFist program (skilled nursing facility specialist). All our efforts will be guided by our goal of making health, and health care, easy for our patients and members.
How do you foresee palliative care developing as an industry during the next five years?
To some degree that will be dictated by policy. Whether that is payment reform for community-based palliative care programs or alterations of the Medicare Hospice Benefit.
Payment reforms will be critical for community-based palliative care programs to maintain sustainable business models. I also suspect that there will be more consolidation within the industry at large.
We will increasingly leverage data and technology to improve specificity of patient selection. Palliative care programs will continue towards seeing patients based on need and not based on diagnosis, but it is going to take many iterations of processes to get there.
