Strong staff education and reimbursement are among the keys to successfully integrating social determinants of health within a palliative care program.
Screening tools developed by the U.S. Centers for Medicare & Medicaid Services’ (CMS) include five areas of social determinants of health: food and housing insecurity, transportation needs, utility difficulties and interpersonal safety. Supplemental domains include financial stability, employment and family and social support, among others.
Training interdisciplinary staff to identify and address patients’ nonmedical needs is a significant component of quality palliative care delivery, according to Dr. Tracy Romanello, medical director at Catholic Hospice and Catholic Palliative Care Services.
Assessing patients’ most challenging practical and financial issues takes insightful communication skills alongside a deep knowledge of resources available to them, Romanello said at the Hospice News ELEVATE conference in Orlando, Florida.
“Does palliative care intersect with social determinants of health? That is the happiest marriage,” Romanello told Palliative Care News at the conference. “As palliative providers, I always train students in the essence of trying to understand what makes people tick. You’ve really got to peel the onion back to identify what is most important to them, who is most important to them and what are the constructs to optimizing their health care. If you’re not serving as an advocate for health equity, food disparity and access, then you’ve missed the boat as palliative providers.”
Hospice News photo by TBAR Productions Hospice News photo by TBAR ProductionsChallenges abound
Having a sufficiently trained workforce is just the tip of the iceberg when considering the integration of social determinants of health within a palliative program, Romanello indicated. Other important elements include balancing clinical capacity and financial support for these services, she stated.
Catholic Hospice and Catholic Palliative Care Services is part of the Florida-based Catholic Health Services of the Archdiocese of Miami. In addition to palliative and hospice care, the health system provides hospital-based and outpatient rehabilitation, skilled nursing, assisted living and home health care. Its daily palliative care census hovers around 250 patients in both hospital and community-based settings.
Assessing social determinants of health in community-based palliative care can be particularly challenging, according to Romanello. Patients often have a diverse range of unmet needs that can strain interdisciplinary teams’ capacity amid staffing shortages and limited reimbursement options. Palliative providers need greater access to community collaborations and ample funding when it comes to addressing a patients’ full range of spiritual, financial and emotional pain points, Romanello stated.
“Until we have a payer solution for this, it’s going to be challenging because you’ve got to try and get as close as you can to the green zone, and many palliative programs are bleeding,” she said. “How do you not have burnout for your staff? That was tricky in the community too. We can’t fix all of this, and they get exhausted because they’re looking for strategies. We’ve got to get the basic elements to get the solutions for some of that.”
Hospice News photo by TBAR Productions Hospice News photo by TBAR ProductionsA foundation in care management
Understanding insurance coverage of social determinants of health is key for palliative care providers, which often operate on meager reimbursement, according to Dr. Cameron Muir, CMO at the National Partnership for Healthcare and Hospice Innovation (NPHI).
Knowing the available reimbursement options are available is part of building a sustainable infrastructure that can demonstrate the return on investment (ROI) of social determinants of health, Muir stated. Care management is a critical component for palliative care providers to leverage, he said.
“You’ve got to start somewhere, and you’ve got to have an infrastructure that can demonstrate outcomes,” Muir told Palliative Care News at the conference. “And then you can go to something a bit more financially sustainable. Probably understood, but not talked about enough is [the] care management infrastructure that you’ve got to have. This is a rose between two thorns where people are actually profitable because there is a net margin on care management with clinical staff that actually makes up for the providers that can barely break even.”
Hospice News photo by TBAR Productions Hospice News photo by TBAR ProductionsThis kind of care management can help providers gather patient data that can be tied to improved outcomes and cost savings, Muir said. The value proposition of palliative care paired with social determinants of health services comes in the form of fewer hospitalizations, improved quality and better management of nonmedical challenges, he added.
“If you can do care management … it’s not only the right care model, but now there’s actually reimbursement for it,” Muir said. “CMS has shown, if you look at complex chronic condition data, there is an asymptotic curve [of] the more complex chronic conditions you have, the more expensive your care is likely to be. So if you then train the social worker or the [licensed practical nurse (LPN)] to be a community health worker, and then do a social determinant screen, you’ve got care management that’s actually got legs on the ground of the community needs.”
Building solid partnerships
Among the sustaining elements for social determinants of health services is having a diverse community and payer partnerships, according to Dr. Darren Schulte, CEO of Vynca. The company launched as an advanced care planning technology platform and expanded into the palliative care provider space through its 2021 acquisition of California-based Resolution Care. In 2022, the company rebranded as Vynca to reflect its broadened scope of clinical services and now provides care across five Western states.
Much of Vynca’s palliative care services are delivered to individuals in very rural and underserved areas, Schulte said. Roughly 60% of the services are provided to Medicaid beneficiaries. A few states have Medicaid programs that offer palliative care benefits, these often do not sufficiently cover the full range of interdisciplinary services or social determinants programs, he stated.
The reimbursement shortfalls mean palliative care providers have to be nimble to find social determinants support, according to Schulte.
Successfully implementing assistance for social determinants of health requires interdisciplinary teams to connect patients with the appropriate resources, Schulte stated. Solidifying partnerships with community organizations, other health care providers and payers is a crucial part of sustainability, he said.
“The hard work is the guidance, the assistance and the closing of the loop to ensure that [patients] get the disability, the housing grant, the food or the concierge transportation,” Schulte said during the conference. “Because there’s an ROI to good palliative care, we’ve worked with health plans in a strategic manner [to] have contracts that are risk-bearing where you can provide comprehensive outpatient palliative care that includes things that we know generate outcomes and value, which is attending to the social determinants. The critical need here is to have those relationships because health plans do see it, they just need to have the demonstrated outcomes.”
Hospice News photo by TBAR Productions Hospice News photo by TBAR Productions