National Hospice and Palliative Care Organization Palliative Care Resource Series Should our Hospice Provide Palliative Care? Conducting an Organizational Assessment Gretchen Brown, MSW former President and CEO of Hospice of the Bluegrass

Objectives Discuss the potential benefits to a hospice offered by a palliative care program Describe the importance of a needs assessment when considering palliative care services Compare potential palliative care program models Identify financial considerations when implementing a palliative care program

Hospice as the Palliative Care Provider A successful palliative care program depends upon Sufficient community need Adequate financial resources Ample clinical resources and clinical expertise

Hospice- the Ideal Provider of Palliative Care Hospices: Understand palliative care concepts and interventions Are experienced at discussing pt/family end-of-life wishes Can describe advantages and disadvantages of treatments Are certified and specially trained to care for patients who are appropriate for palliative care Have experience providing care in a variety of settings

Is Palliative Care Needed in my Community? Conduct a Needs Assessment/Feasibility Study Type of palliative care program Adequate staffing and financial resources Internal staff discussion of pros and cons Involve administrative and clinical leaders Medical director Financial staff Representatives from partners or potential partners Form a planning committee!

Program Development Investigate potential program models Develop a list of community programs already offering services Investigate potential program models Determine capacity and resources of hospice provider Examine financial and budget issues required to develop, grow and sustain Uncover additional helpful resources

Program Development: Community Programs History Competitors were few when hospices began to offer palliative care Hospitals provided in acute care setting Today Palliative care offered by most hospitals Some hospitals provide palliative home care Many nursing homes, home health agencies, private physician practices, insurance companies provide palliative care

Program Development: Community Programs Potential patients PACE programs Transitions programs Private or institutional case management programs

Program Development: Community Programs Evaluate available services History Competence Community reputation Location Is there a gap in services? Where?

Program Development: Investigate Program Models Inpatient acute care model using one to a full range of palliative providers in a hospital setting Outpatient model providing services in a skilled nursing facility or patients’ homes Independent clinic or palliative medicine practice

Program Development: Determine Capacity Identify knowledge deficits Advanced clinical knowledge of aggressive treatment for diseases Understanding of operation, regulations and goals of different settings Home Hospital Nursing facility Long term acute hospital Challenge of 24 hour on call services

Financial Considerations: Hospices Palliative care programs – decrease cost of care for medically complex patients Payment to hospice organization is limited Medicare Part B and insurance payment Physicians and nurse practitioners Other billable physician extenders Social workers in some outpatient settings Hospitals, insurers and managed care may have special arrangements

Financial Considerations: Healthcare Systems Hospices within healthcare systems – easier time funding palliative care program In system ‘credit’ for cost savings/cost avoidance to overall system can fund new program Examples: Kaiser – multi-state entity serves as healthcare provider and insurer Mt. Carmel in Columbus, Ohio Sharp system in San Diego, California Sutter in the Bay area Comprehensive systems in which health system owns the continuum of acute care, home care and hospice

Financial Considerations: Collaborative Models Health system funds palliative care Supports large percentage or entire program Offers subsidies for visits Collects for billable service or allows hospice to do so (subtracting the billings) Healthcare system may provide non billable staff or contract from the hospice Can be effective for acute care, home and clinic models Can break even! Example- Hospice of the Bluegrass

Financial Considerations: Fee for Service, Per Diem or Capitated Rate Partner with large insurance company Insurance company agrees to pay for service, per diem or capitated rate for home based palliative care Creative Programs – Hospice of Michigan’s @HOMe Developed contracts supplying adequate number of patients and payment System for evaluating the savings generated to health system

Financial Considerations: Fee for Service, Per Diem or Capitated Rate Medical homes Contract with hospice organizations to provide palliative care to patients where capitated rates are common. Stable base for homecare program Dependable partner – insurer, union, Accountable Care Organization Income and referral stream

Hospice as the Palliative Care Provider Most difficult model to sustain Inpatient programs may breakeven if enough consults Travel for homecare erodes limited patient billing

Analyzing the Demand and Making the Budget Knowledge about patients or beneficiaries Value of cost avoidance palliative care program reduces costs prevents inpatient admissions leads to earlier hospice admissions Volume of services to estimate income and expenses

Analyzing the Demand and Making the Budget To do’s for the hospice Obtain Medicare Part B billing number Billable practitioners need to be credentialed with other payers (Medicare and private insurers) Payments vary Setting where service is rendered Type of service Type of visit Duration of visit Number and type of each visit will need to be estimated

Analyzing the Demand and Making the Budget To Do’s for the Hospice Calculate difference between cost and income Initially bottom line will be negative! Determine if deficit will be offset by Service differentiation Partnership or customer development Potential for additional patients Potential for increased length of stay

Other Considerations Pilot programs Help determine potential success of new program Inpatient program – one service or one floor in a facility for specified time Home based program – 20 referrals from hospital or insurer Help staff understand strengths and weaknesses Reveal unexpected challenges and opportunities

Other Considerations State and federal regulations Impact how program is organized and implemented Legal advice from healthcare attorney early in planning process Hospice can benefit from partner’s legal counsel – should also have its own

Other Considerations Additional resources Philanthropic support for startup and ongoing Family Healthcare systems Community foundations Educational resources Hired consultant

Conclusion Hospice organizations are ideal palliative care providers and partners Education and planning are key to deciding to provide palliative care Only if quality services can be provided at a cost that does not negatively affect the hospice!