What drove hospitals’ rapid expansion of palliative care

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 - J. Brian Cassel, PhD
J. Brian Cassel, PhD

In 2000, less than 25 percent of U.S. hospitals with more than 50 beds had palliative care teams. By 2015, that number had jumped to 75 percent, which, according to a study published in Health Affairs, can be largely attributed to training and leadership initiatives.

Led by J. Brian Cassel, PhD, palliative care research director at Virginia Commonwealth University, the study said dissemination of this multidisciplinary approach can be credited to the Center to Advance Palliative Care (CAPC) and its training initiative, Palliative Care Leadership Centers (PCLC).

CAPC, founded at the Icahn School of Medicine at Mount Sinai in New York in 1999, aimed at expanding access to palliative care by promoting the specialty, motivating hospitals and physicians which may be interested and offering a variety of tools to help facilities plan, implement and maintain palliative care programs.

“CAPC’s strategic focus on technical assistance to the field reduced the opportunity cost of startup and stimulated rapid growth in the numbers and quality of palliative care programs,” Cassel and his coauthors wrote. “As a result, the programs and their leaders had increased capacity to demonstrate both quality and financial outcomes for their institutions, in turn driving senior executives’ commitment to sustainable financing from operating budgets.”

In 2015, it became a membership organization for hospitals and health systems with palliative care programs, encompassing more than 1,100 organizations.

Many of those programs started thanks to the PCLC initiative, launched by CAPC in 2003. Hospitals in selected states could apply for the program, which began with building a palliative care team (with a “substantial discount on tuition” if someone from the finance department was included) and then moved onto two and a half days of in-person training.

“One participant described the PCLC training as a ‘mini-MBA’ and said that it was more useful to him than the executive MBA program he had completed the year before,” Cassel and his coauthors wrote. “Topics include needs assessment, working with key stakeholders, staffing models, financing options, internal and external marketing, measuring and reporting outcomes of importance to key stakeholders, identifying and working with community partners, and implementation.”

The face-to-face training was followed by a year of “distance mentoring,” with an emphasis on making the PCLC program fit each facility’s individual needs. The final goal would be to be eligible for the Advanced Certification Program for Palliative Care from the Joint Commission.

The training initiatives appear to have paid off. More than 1,240 teams were trained through PCLC (including 148 from veterans’ care facilities) between 2004 and 2017. About 80 percent of the participating hospitals had launched their own palliative care programs within two years of attending the training. Teams from almost two-thirds of the hospitals which have those programs. Teams from about two-thirds of the hospitals had attended PCLC training.

There have been limits to the reach of the expansion, however. Examining American Hospital Association survey data from 2015, Cassel and his coauthors found that among hospitals of all sizes, for-profit hospitals were far less likely to have palliative care program than nonprofit or public hospitals. Similar patterns were seen among other “high-value, low-revenue” programs like hospice services or psychiatric consultation programs.

“Dissemination of high-value, low-revenue innovations in healthcare takes dedicated expertise, persistence, and ingenuity. In the case of palliative care, strategic and sustained investments by philanthropies and purposeful efforts by experts fostered large-scale dissemination over the past two decades,” Cassel and his coauthors concluded. “Despite current fee-for-service incentives that do not encourage the use of palliative care, more than 80 percent of patients with serious illness hospitalized in the US now have access to these services.”