Palliative Care in the Safety Net: Advice on Ensuring Access, Quality, and Stability

Palliative care has grown rapidly in the last twenty years. Yet, access lags in public health systems, rural health organizations, federally qualified health centers, and other organizations predominantly serving Medicaid, uninsured, and underinsured populations. While availability lags, there is also evidence that patients served by safety net providers have greater and more intense palliative care needs when compared to general patient populations.

Despite the hefty challenges, palliative care programs in the safety net have a tremendous impact on their patients and communities. In an effort to celebrate and support these palliative care professionals, the Center to Advance Palliative Care (CAPC) launched a Learning Community in 2023, where palliative care leaders from resource-constrained organizations have gathered to share their ideas. To date CAPC has held four facilitated conversations, and this blog highlights some of the creative and practical strategies shared.

Not surprisingly, the first conversation focused on securing additional funding and staff, a theme that continued to be a trend throughout all of the conversations. Some of the advice leaders shared included:

• Foundation grants are a great way to expand to a new service or population. The advantages of using grants included the opportunity to “write once and use multiple times” and the continuation of support for successful efforts. One leader noted that grant requirements have helped secure an organizational commitment to sustain expanded palliative care services.

• Improved palliative care education across the organization has helped some programs to create demand for additional palliative care specialist hires. For example, one organization trained all outpatient care managers in palliative care communication skills. As conversations became standard practice, ambulatory care leadership budgeted for an additional palliative care specialist to support their patients with complicated needs.

• Some leaders leverage their impact on important outcomes for contributions to the palliative care team’s salary costs. One organization used palliative care’s impact on HEDIS quality measures to gain financial support from their quality management group, and another gets financial support from the Emergency Department because their services help with some key reimbursement metrics.

• Many safety net palliative care teams “borrow” staff from other services where goals align. Examples included programs that utilized hospital care managers to hold goals of care conversations, psychiatry residents to support mental health needs, and chaplaincy interns to supplement the palliative care chaplain’s impact.
  
  One team has formalized a “palliative care liaison” role within their nursing, pharmacy, and psychiatry departments. The palliative care physician typically does the initial consultation and signs off, with the liaison handling follow-up care. In addition to expanding palliative care’s resources, this program found that assuming the liaison role helped with burnout for the professionals who rotated into this role.

Palliative care leaders in the safety net and rural settings are acutely aware of the need to prioritize patients served and have developed strategies that ensure meaningful contributions within the available bandwidth. Many clinicians leading outpatient palliative care clinics shared struggles with the volume of patients. One leader shared how she originally took all referrals and slowly had to limit the service—first to oncology patients only, then to Stage 4 patients only, and ultimately, only to those patients with “a primary clinical need.” In response to this story, her peers confirmed the wisdom of this prioritization and shared a few other strategies that included:

• Surveying palliative care team professionals to identify the patients for whom palliative care had the strongest impact, then using that information to outline service criteria.
• Asking referral sources to estimate prognosis to better prioritize more urgent versus standard wait time appointments.

A rural leader shared how limited resources led to the termination of inpatient palliative care at a particular hospital, which spurred new admission processes that included standardized goals of care discussions. While far from ideal, this at least filled a gap and improved patient and family experiences, which has led to new discussions about the return of palliative care consultations via telehealth.

Another common strategy that helps manage existing resources is educating referrers and collaborators. In other words, managing expectations. Some examples of this include:

• Communicating about declined referrals with the referring clinician, clarifying reason(s) for not seeing the patient, and assisting with an alternative plan. This way, patient needs are met while the referring clinician is educated on appropriate palliative care consultations. Some leaders used the EMR to document options for care outside of palliative care.
• Making it crystal clear that their inpatient palliative care team is a consultative service. Once the patient is seen, their recommendations are entered into the EMR, and the patient is only seen again as either indicated by the primary team’s care plan or the palliative care team’s plan.
• Some leaders noted that they follow patients both inpatient and outpatient, and utilize EMR tools to be notified about admissions to trigger a palliative care visit. This practice is welcomed across all services and expedites attention to palliative needs.

Lastly, telehealth was a common strategy deployed in safety net and rural organizations for outpatient services. No-show rates were noted to be lower for virtual visits, and estimates were given that visits could be 20-25% shorter. To promote a better team environment, participants suggested co-locating the telehealth clinician(s) with the rest of the team. In an effort to improve equitable access, several leaders noted the use of Wi-Fi-enabled loaner devices, with high rates of device return.

In addition to the strategies outlined above, other useful insights from the far-ranging discussions included:

• The utilization of one faculty or staff member to do both inpatient and outpatient responsibilities has helped team wellness and patient continuity.
• Participating in state advocacy efforts to lead legislative changes and reimbursement for services.
  • An example of this included the Washington State Department of Health paying for case conferences and office hours to expand palliative care in the state, especially in remote, rural areas.
  • In Louisiana, leaders could advocate to the Louisiana Department of Health to reimburse for prolonged care and advance care planning codes.
  • Palliative care champions in other states are also advancing payment opportunities, including Medicaid benefits for community-based palliative care services and pediatric palliative care.

We are excited to continue supporting palliative care leaders in safety net and rural settings. If you work in a relevant organization and want to be included in future conversations, please email Allison Silvers. The Arthur Vining Davis Foundations has generously supported this Learning Community, and the authors express their extreme gratitude for their support.

Edited by Melissa Baron. Clinical review by Andrew Esch, MD, MBA.