To meet growing demand, more outpatient palliative care clinics and programs are cropping up.
Insurance companies and Medicare are also starting to recognize the cost savings and improved patient outcomes the clinics can provide.
“I think what we are realizing is that the majority of Americans with chronic illness actually are not dying, and they’re living in our communities,” Dr. Jane Schell, section chief of palliative care and medical ethics, division of Nephrology at the University of Pittsburgh Medical Center (UPMC), told Palliative Care News.
All palliative care, no matter the setting, seeks to alleviate symptoms and pain for people living with chronic illnesses. As it is not end-of-life care, patients can continue to receive life-prolonging or curative treatments, which they cannot receive if choosing hospice for most conditions.
When a patient is hospitalized with a serious condition, such as cancer, heart failure or COPD, the hospital may activate its internal palliative care team to help the patient establish lifestyle goals prior to discharge. The patient will then be referred to an outpatient clinic or home-based provider for further care.
Patients should have access to a palliative care provider early following a diagnosis of a serious illness, according to stakeholders. The recommendation from the American Society of Clinical Oncology is that outpatient palliative care is offered within the first eight weeks following a cancer diagnosis. This allows patients and their providers to build a rapport that can last throughout the illness — especially when the patient’s prognosis changes.
“Outpatient palliative care is not about seeing someone for the first time and calling hospice,” Schell explained. “Sadly, sometimes that’s what we’re doing.”
In May, Wilmington, North Carolina-based Novant Health Heart and Vascular Institute launched an outpatient program to help address several needs of palliative care patients.
“With our outpatient palliative care program, we start early,” Erin Lambert, heart failure program manager, Coastal Market, at Novant Health, told Palliative Care News. “This allows us to help our patients better understand heart failure and how to manage their symptoms in a way that achieves their goals.”
Meeting patient goals involves creating a comprehensive, multidisciplinary care plan tailored to each patient, Lambert explained. The patient, their family, their doctor and other care team members work together to create the care plan.
“Heart failure can significantly impact the daily life of our patients and symptoms can interfere with how individuals want to spend their time,” said Lambert. “This reality presents a valuable opportunity for palliative care to directly support patients by focusing on their lifestyle and goals.”
The majority of outpatient palliative care clinics are found running alongside diagnostic and treatment centers for specific conditions, Schell explained.
In the case of cancer treatment, this allows patients to see their oncologist and their palliative care team in the same day, without the need for multiple appointments. It also allows for better interdisciplinary care, as embedded clinics can share team members across disciplines.
Palliative care providers are also embracing telemedicine to help patients manage their symptoms and keep their appointments. Patients can set up a telehealth check-in with their team rather than make a clinic visit.
In the face of staffing shortages, especially of nurses and social workers, telehealth also helps coordinate visits with those team members, Schell explained.
“There are several different models of care that have looked at getting really specific about the palliative care needs a patient [and their family] might have,” Schell said. “We’re used to the traditional clinical setup, where you’ve got 60 minutes for this patient, and 30 minutes for this patient,” Schell said. “But that traditional outpatient setup doesn’t exactly match the needs [of the patients] or how I would like to practice outpatient medicine.”
Reimbursement for palliative care services remains scarce. Traditional Medicare will cover physician or advanced practitioner services, and Medicare Advantage plans may cover palliative care as a supplemental benefit. Outpatient palliative care, though, is billed similarly to a cardiologist or primary care visit, Lambert said, meaning patients may pay less out-of-pocket for the service.
Schell explained that some private insurance companies have implemented home-based palliative care benefits, but that some may not cover the full range of interdisciplinary services.
“A lot of our work is prescription management, especially for serious illness pain. You’re making sure you’re doing smart opiate management,” Schell said. “Physicians aren’t the most important people in the world. You need nurses. You need schedulers and social workers. Those sorts of pieces are critical to a thriving and growing program” whether in the clinic or in the home.
Novant Health is tackling that problem head-on, coordinating in-home outpatient care for patients who aren’t able to make the trip to the clinic, Lambert said.
The company is also developing a ventricular assist device (VAD) program. A VAD helps pump blood from the lower chambers of the heart to the rest of the body and is a treatment for heart failure. Currently, patients in the coastal region of North Carolina must drive several hours to receive this care, Lambert explained.
“Bringing this service to the region will allow Novant Health to extend a life-changing care option for our community,” Lambert said.
The rise of palliative care outpatient clinics signifies a transformative shift in health care, focusing on patient-centered care for those facing serious illnesses. Obstacles to widespread implementation remain; however, including education around the service. Many patients, Lambert said, misunderstand the purpose and conflate it with hospice care, which can lead to delays. Some providers even misunderstand the type of care offered, so don’t refer their patients.
In May 2022, Sen. Tammy Baldwin (D-Wis.), introduced the Palliative Care and Hospice Training and Education Act (S. 4260) to help combat some of the confusion providers face and build out training programs for professionals to encourage more medical, nursing and social work students to enter palliative medicine. This could help relieve some of the staffing pressures on the profession.
“We need to reframe how we think about palliative care,” Schell concluded. “It is not how people die, it’s how they live. And I think that outpatient palliative care is actually the steps to help us get there.”