03.24.2022

Defining Palliative Care: It’s Not Hospice Light

By Maureen Kelleher RN, MBA Senior Manager  

Palliative Care is the care of patients with serious illness who have symptoms throughout the illness, not just at life's end, and is provided while the patient is also receiving curative treatments for the illness.

The goal of incorporating Palliative Care into the health system is to improve the symptoms of an illness or side effects of the treatments, thus enhancing a patient's quality of life. It is also to provide an open communication with patients and families regarding goals of care and advance directives. Palliative Care involvement early in disease treatment could assist home health providers in reducing hospital admissions, which will be monitored more closely as 35% of a Home Health Value-Based Purchasing score will come from hospital claims.

In short, Palliative Care is the safety net for patients as they traverse the medical journey of their illness until such time that the illness is either cured or the treatments are no longer beneficial and life expectancy is considered to be less than six months.

Multiple models of care

Why is Palliative Care so different depending upon who is paying for it, who is providing the care, or who is regulating it?

When Palliative Care became a separate care line, there was no supportive structure for providers or payers. The term Palliative Care was being confused with Hospice because Hospice has always provided Palliative Care or symptom management. A different name may have resolved some of this confusion. Palliative Care also encompasses transitional care, chronic care management, advanced illness management, and many other models of care. Agencies continue to believe there is little to no reimbursement for these services and fear they will not be able to maintain a program. There are also several Palliative Care staffing models being used, which causes even more concern regarding financing a program.

Important considerations

Defining Palliative Care to be a medical practice of symptom management early in a patient's diagnosis and focusing on specific diagnosis categories that typically require symptom management is key. Categories such as Cancer, Cardia, Pulmonary and Renal Diseases are the obvious categories to start with. Both the symptoms of the illnesses and the side effects of the treatments lend to a need for Palliative Care services. Caution should be taken to ensure there are serious and potentially progressive diseases causing the symptoms to be managed to avoid becoming a "pain clinic."

Palliative Care can be provided in several settings: Inpatient, Clinics, Home, Facilities. A program able to provide services in all settings may be the most successful.

Starting a patient on Palliative Care at or close to the diagnosis of a serious illness is needed to help patients manage symptoms and to help define what quality of life means to them as they go through the treatments. Planning for any potential crisis so decisions can be made without being in the middle of the crisis. Also, helping patients communicate their goals to family members and, when appropriate, getting advance directives in place to ensure the patient's wishes are followed.

Patients who receive Palliative Care services early do not always need home health services and should not be on death's door waiting for someone to have the "talk." Palliative Care starts long before these other services are needed. Programs will need to have good relationships with Home Health and Hospice agencies so when the time does come for these services, there is an easy referral process. Fortunately, a patient can receive Home Health services and Palliative Care services concurrently.

A good Palliative Care program will also be able to help patients decide when treatments are no longer providing the quality life as they have defined it and will be ready to enter Hospice Care sooner. Thus, allowing the patient and family to experience the full benefits of interdisciplinary hospice care and reducing the cost of healthcare and patient suffering through futile treatments.

Reimbursement for Palliative Care

How can a Palliative Care program get reimbursed?

The most efficient and practical way to set up a Palliative Care program is as a clinic/group practice. The only visits that are reimbursed are Physician, Nurse Practitioner and Licensed Clinical Social Workers.

A Palliative Care program can complete home visits for patients who are too sick to get to the doctor, are immune-compromised, or have other specific reasons requiring a home visit. Sharing space within an established clinic for specialist or primary care can reduce overhead costs and provide easy access to those patients already seeing these providers. A program could also coordinate community care with any hospital inpatient programs to maintain consistency. Or, if a hospital did not have an inpatient Palliative Care program, a community program could work with a hospital system to contract services.

What are the pitfalls?

  • Setting up Palliative Care as if it is Hospice Lite. Hospice is for end of life. Political efforts might be better spent on improving access to quality healthcare and educating healthcare workers.
  • Setting up Palliative Care as a feeder for hospice. Yes, eventually many of the Palliative Care patients will need hospice, but done correctly, Palliative Care can provide much needed care years before hospice. Palliative Care should not be the "let's get Palliative Care in to tell the patient they are dying" program.
  • Including nursing, personal care aides and other services into Palliative Care. These services are already available to patients. Efforts to improve access to these services is more important than trying to reinvent the wheel. Politically and financially, allow patients easier access to home health services, review and remove any requirements that are barriers to care (inpatient stays, reason for services). There are many patients who could use more help at home, but insurances stand in the way with many of the requirements. An 85-year-old woman with a broken clavicle and dementia will need OT and an aide until she can move her arm and shoulder; why wouldn't that be covered by all insurances -- or at least partially covered?
  • Not setting Palliative Care up as a separate entity. Palliative Care should have its own NPI number and should be enrolled in Medicare Part B. There are evaluation and management visit codes for visits in the home, facilities, and clinics. Scheduling visits and utilizing providers who can bill will get your program reimbursed.

SimiTree can help

With a full array of clinical, operational and financial consulting services as well as outsourced billing and coding services, SimiTree has the resources to help your organization make strategic decisions, manage growth and increase profitability. Reach out to us today to learn how we can help your organization become healthier overall.

Maureen Kelleher RN, MBA
Senior Manager

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