Healthcare reforms that promote integration of care across treatment settings facilitate feasible and cost-effective outpatient palliative care, suggest findings from a sustainable community-based model of care.
"[Outpatient palliative care] has potential to support patients as they transition from hospital-based palliative care to community-based care and hospice, thus preventing them from 'falling through the cracks' in the current array of services," say Janet Bull (Four Seasons, Flat Rock, North Carolina, USA) and colleagues in the Journal of Pain and Symptom Management.
While the number of hospital-based palliative care programs in the USA has increased rapidly, availability of outpatient palliative care remains limited. The researchers say that multiple barriers, including lack of service integration, impede the financial viability of these programs.
Follow-up of an outpatient palliative care program launched by Four Seasons in 2003, aimed to identify organizational and financial factors associated with financial losses approaching US$ 400,000 (€ 301,613) per year.
Quality Assessment and Performance Improvement cycles identified a number of challenges to palliative care program sustainability, including issues in treatment quality, lack of referrals, inexperienced providers, limited physician resources, and poor system compliance and financial administration.
When the researchers implemented a number of action plans to address the shortcomings identified across the five domains of quality, compliance, people, growth, and finance, financial losses decreased by 40% in 2011.
Examples of the actions implemented to improve care include developing standardized palliative care visits, educating providers on prognostication and end-of-life discussions, educating the community on palliative care facilities, developing education and training programs, hiring physician assistants, improving billing and copayment collection, and investing in technology and technical support.
"Although not every organization will identify a need in each area, we suggest that it may be helpful to evaluate potential needs across a reasonably comprehensive spectrum of functional areas… to understand which aspects of the organization's performance work well and which ones warrant attention/improvement," say the authors.
Bull and team note that the observed financial improvement occurred in line with an increase in the number of patients served per day (from 305 patients in 2008 to 620 patients in 2011) and expansion in treatment staff (from 10.5 to 14.0 providers including physicians, nurse practitioners, and physician assistants).
They add that further refinement of the model based on ongoing evaluation will allow palliative care organizations such as Four Seasons to minimize losses, develop strategies for funding, ensure high quality of care, and maintain high levels of provider competence and satisfaction.
"Together, these achievements amount to sustainability for a palliative care program in the current US healthcare environment," concludes the team.
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