The health care performance improvement company Stratis Health has developed a framework for expanding access to palliative care in rural communities.
The company’s strategy convenes resources and organizations that already exist in a given community to help meet patient’s palliative care, psychosocial, spiritual and social determinants of health needs. It leverages those resources to offer a wraparound suite of services for seniors and seriously ill patients.
Hospice News spoke with Karla Weng, senior program manager for Stratis Health, about how health care providers and other stakeholders serving rural communities can come together to better serve their patients and clients.
What are some of the unique needs of rural populations when it comes to palliative care?
There’s a variety. Certainly we have folks in rural communities who tend to be older, sicker and poor. Oftentimes people have more comorbidities, less income and greater distances. One of the biggest issues is transportation and distance and access to services.
Most places have some primary care access, but access to specialty services is often a challenge. Transportation for those services, if you need some of the wraparound services and therapies, home care, for example, is often not available. Hospice is often not available. In a lot of rural communities, there’s just not the volume of individuals to kind of support that as an ongoing service.
We have both a population that is more likely to need palliative care services, and access to services is oftentimes more limited. Or if they are available, the transportation component can be a significant challenge.
For the purposes of your program, what definition do you use for community-based palliative care?
When we started doing this work, palliative care was really a hospital-based service, so nobody was really talking about the community. When we talked about community-based, we were really talking about pulling together a variety of organizations working together in the community to offer services. Oftentimes they might be in the hospital, but oftentimes it’s further upstream.
The field has shifted in more recent years, so that community-based really means anywhere but the hospital. It might be in a clinic. It might be home care. We’re not that prescriptive. So we have sometimes shifted to using the language “community centric.”
The way that we work with communities who are interested in going down this path is helping them first to do a gap analysis and assessment of the resources that are already there in their community. How do you tap into what’s already there? What are the gaps and how do they align with the needs in your community? And then how do you start to pull that together and build capacity and skills and resources to make those services happen? So that might look different depending on what resources and needs are in your community.
It might be traditional clinic visits. It usually isn’t. Oftentimes it’s either combination of home visits and telephonic services. Sometimes they might be doing consultations either inpatient or in the nursing home or in assisted living. So sometimes you have that sort of model.
Sometimes it’s wraparound services, so you have an organization that’s doing some of the care, but maybe they need volunteer visits, or they need some of those other health-related social needs support, so connecting those dots. Chaplaincy services may or may not be available through the health care system, so oftentimes others engage with local clergy.
It’s really trying to target and help ensure there’s a common understanding of what palliative care is in the community, particularly around health care. Oftentimes, there’s community education as well, and then working with those communities to identify the different ways that you can tap into resources to help meet those needs.
What other kinds of stakeholders do you engage with during these processes?
For sustainability, the way we have approached this is that we ask for there to be a lead organization in each community, like somebody has to sort of own the activity and coordinate. That is typically the health care organization. Oftentimes, either somebody at the hospital, maybe at the home care in rural communities. Oftentimes, we say the hospital, but the hospital also manages the home care and the long term care.
Typically, that is somebody from the health care community who’s leading the charge and is the coordinator or the team. We do strongly encourage, obviously, the clinic, the hospital, the long term care, the home care (if it exists), hospice (if it exists), assisted living, all the sort of clinical services that might be in the community. But from there, it actually varies quite widely — extension agencies, senior centers, area agencies on aging, EMS, whatever else might be in that community that makes sense.
What’s the structure for that? Do they have contracts with one another? Are there formal partnerships?
That mixes and matches across the community. So I think I’m not sure about the contracting piece. It’s more around what piece you can already do and how the connection and communication is happening. So one organization might offer service X and there might be service Y. Here it’s the connection and the flow of that together.
Can you tell me more about the framework that Stratus has developed for reaching these rural patients?
We have developed a framework that helps community teams essentially walk through that process of how to develop services. So over the years that we’ve been doing this, we’ve recognized that, oftentimes, there’s really some foundational starting blocks that people need to start with in their community. So certainly, doing an assessment, understanding what the gaps and assets are, is a key piece.
As you’re looking at that, there’s some foundational components. For example, who’s doing advanced care planning? How’s it being documented? Who is aware of it? It’s trying to get to some community standards and commonalities around some of those sort of key processes that are related to palliative care. So advanced care planning is one. Clinician education in skill building is another.
There’s often a community education component, helping people understand what palliative care is. There’s a lot of confusion between hospice and palliative care. How do we tease those out? What’s those types of things? Those are really kind of foundational components that we see.
We encourage folks to start small. We’ve had communities that have started with patients who are receiving infusion therapy, or patients who are hospice eligible but have refused hospice. So how do you kind of start to pilot that out? What are your workflows? What does that communication process look like? How are you touching base with the patient? How are you communicating with each other? It’s working through that process while at the same time also considering and thinking about what is your business model.
Would you expound on the business model? What does that look like?
Most programs end up doing, I would say, sort of a braided model of reimbursement or funding. There’s always an underlying value point. People do figure out ways to provide these services, because it’s the right thing to do for their community. Oftentimes it helps reduce clinician stress. There are things that are valuable that don’t necessarily have dollars attached directly. It’s good for our community. It’s good advertising.
Then there are different kinds of payment mechanisms. There are things you can bill for, particularly your traditional Medicare; you can bill for some of the clinician visits. You can bill for advanced care planning. You can bill for chronic care coordination. So there’s that whole set of things that you can actually get directly reimbursed for.
Then we have programs that oftentimes tap into some sort of philanthropic dollars. It’s more challenging to have that as an ongoing payment mechanism, although some may use it to kind of offset some of the costs.
What is really growing is, as we see a shift in the payment environment, meant to add more value into our contracts with payers. So palliative care can help reduce avoidable hospital utilization, reduce emergency visits, those types of things that are then incentivized in a value-based contracting structure that aren’t under fee for service.
So if I’m focusing on palliative care for a portion of our population, then I’m able to reduce ED visits and hospitalizations. I’m offsetting costs, and that is going to help me get my incentives under a value-based care contract. So easier to say you have money coming in than to say you’re saving money, but we usually see people have kind of a combination of those.
How do you go about implementing this framework? How do you connect with these organizations that are providing the care and bring them together?
We’re based in Minnesota, so we have done a lot of this work directly ourselves in Minnesota, with partners. Stratis Health does a lot of work around quality improvement and improving population health. So we have direct connections to health care organizations. We would invite them to participate.
The more recent rounds of the work we’ve done has actually been in other states. We have partnered with organizations in other states that are typically the state office of rural health, which exists in all 50 states. They tend to be well connected in their rural communities. So we have coordinated with the State Office of Rural Health, who has done the outreach.
We see that kind of capacity building. Our intent in doing that is to train the State Office of Rural Health staff so that they can sustain and continue to support the providers and the communities in their state. We have done this work in Washington, North Dakota and Wisconsin, and then we’re actually just getting started on initiative with the Michigan State Office of Rural Health.
