Palliative care improves the care of seriously ill people — enhancing symptom control, care coordination, communication and quality of life — not just for patients, but also for their families and caregivers. Increasingly, palliative care is recognized for having an even wider impact: assisting health systems and payers in developing systems of care that support population health. Caring for the seriously ill requires a well-coordinated interdisciplinary team that is particularly adept in transitions of care — especially in today’s transforming health care environment. This team-based approach provides additional attention and proactive support to the needs of the patient and the caregiver, whose wellness is affected by the caregiving role.
Palliative care is an increasingly important resource to facilitate integration with community partners and to coordinate complex care needs of patients outside the hospital setting. Established hospital-based palliative care programs function optimally when integrated with ambulatory and home-based settings of care. Examples are demonstrated in stand-alone palliative care clinics as well as palliative care support embedded in specialty ambulatory settings, such as oncology, pulmonary, neurology and cardiology. Palliative teams link to ongoing care in skilled and long-term care settings to facilitate the uninterrupted delivery of complex care plans from hospitals to post-acute. Additionally, home-based palliative care programs are growing, identifying at-risk patients via utilization patterns or algorithm-generated risk profiles. Proactive support for seriously ill people and their families in the home setting leads to less reliance on the emergency department and hospital for exacerbations of illness.
Aligning care with an individual’s and family’s goals is a critical element in care for the seriously ill. Inherent in care coordination across settings of care is the discussion and documentation of advance directives. Exploring “what matters most” helps patients and their families to align care with what is beneficial to support their overarching health care goals. Collaboration and communication across settings of care facilitate the ongoing discussion that is important in advance care planning, as preferences will evolve over time, particularly when illnesses are chronic and progressive.
Structuring the right care at the right time in the right setting for people with serious or complex illness is a priority of palliative care. Palliative care aligns well with payment reform, particularly accountable care models and bundled payments. In the past, the interdisciplinary team structure of palliative care has been inadequately funded in a fee-for-service reimbursement model. With emerging payment models, such as bundled payments or per-enrolled-member-per-month arrangements, team-based care can be optimized, thus more effectively meeting the needs of the seriously ill and their families.
Leaders in palliative care are committed to sharing their knowledge and experience, and an excellent place to learn about their innovations is through the Circle of Life Award — with its sponsors/co-sponsoring organizations of hospitals, hospices, and hospice and palliative care physicians, nurses and social workers. This year’s recipients of the 2016 Circle of Life Award will be featured at the Health Forum and the American Hospital Association Leadership Summit July 17–19 in San Diego. Stories and ideas of all Circle of Life honorees since 2000 are at www.aha.org/circleoflife and interviews with recent honorees can be seen at https://www.youtube.com/user/AHAhospitals.
2017 applications are on the Circle of Life website and due Aug.15. We hope you will consider applying for the 2017 award.
Martha L. Twaddle, M.D., FACP, FAAHPM, is senior vice president of medical excellence and innovation, JourneyCare, Barrington, Ill., and chairs the Circle of Life Award Committee.