This article first appeared on ACP Hospital
By Janet Colwell
More hospitals have invested in palliative care, but such services remain rare in rural areas. Small hospitals often lack sufficient resources to attract specialists and sustain full teams to provide this care for patients with serious illnesses.
According to the 2019 State-by-State Report Card on Access to Palliative Care in Our Nation's Hospitals, the percentage of 50-plus-bed hospitals with palliative care teams grew from 7% in 2001 to 72% in 2018. However, growth has been concentrated in urban areas: Only 17% of rural hospitals have palliative care programs compared with 90% in cities, according to the report compiled by the Center to Advance Palliative Care (CAPC) and the National Palliative Care Research Center.
“Rural areas are ever more underserved as more and more small hospitals are forced to close due to funding constraints,” said Diane E. Meier, MD, FACP, director of the CAPC, which is part of the Icahn School of Medicine at Mount Sinai in New York City. “Many seriously ill patients in rural communities live more than an hour's drive from the nearest hospital.”
Even in populous areas, a shortage of palliative care specialists remains a major barrier, the report found. Many palliative care programs are understaffed and unable to meet rising demand for services, and relatively few hospitals that aren't large or academic medical centers maintain full palliative care teams—which typically include a physician, an advanced practice nurse, a social worker, and a chaplain.
In response, some hospitals and palliative care programs are using telehealth to reach distant patients. While still in the early stages, such programs are showing promise in improving quality of life and reducing costs for the sickest patients.
Cost, quality benefits
Numerous studies have shown that palliative care reduces hospital costs.
Recent data include a meta-analysis, published in the June 2018 JAMA Internal Medicine, which found that palliative care consultation within three days of admission led to cost reductions ranging from $2,893 to $3,581 per patient. Another study, published in the July 2018 American Journal of Hospice and Palliative Medicine, found that palliative care consultations reduced need for future hospitalizations and treatments, saving more than $6,000 per patient. A third, published in the July 2018 Journal of Palliative Medicine, found significantly shorter lengths of stay and earlier referrals to more appropriate levels of care, such as hospice, with no increase in mortality among patients seen by palliative care.
The costs savings come from palliative care's positive effects on patients' quality of life and psychological and physical symptoms, as well as support for family caregivers, according to the CAPC. Studies also suggest that palliative care increases the time spent at home rather than in the hospital at the end of life, which can be particularly meaningful to those living in remote areas.
To provide these benefits, a recent pilot study funded through the Medicaid Transformation Waiver Project established an outpatient palliative care program in rural Northeast Texas to serve 52 mostly low-income cancer patients. Patients attending the program showed significant reductions in symptom intensity and improvement in psychosocial symptoms, such as depression, anxiety, well-being, and spiritual pain, according to the findings published in the April 2019 Hospital Topics.
“Before the outpatient clinic was set up, these patients had to travel long distances to access palliative care,” said the study's lead investigator Gabriela Orsak, PhD, assistant professor in the school of community and rural health at the University of Texas Health Science Center at Tyler. “That's a major challenge for patients who are very ill and often do not have access to reliable transportation.”
Palliative care services delivered via telehealth are generally showing promise as an effective, less costly alternative to in-person care, said Steven Pantilat, MD, professor of medicine and director of the palliative care program at the University of California, San Francisco (UCSF). Some patients even prefer virtual over in-person visits because they eliminate the time and stress of traveling to appointments.
“Telehealth now allows us to deliver palliative care anywhere that patients have access to the internet or cellular service,” said Dr. Pantilat. “Once that connection is established, I can have very meaningful, sensitive conversations with my patients, and their family members can join in no matter where they are physically located.”
Blended model
Resolution Care, an independent palliative care practice based in Eureka, Calif., offers a blend of home-based and virtual care to about 200 patients in rural Northern California. Led by founder Michael Fratkin, MD, a former hospitalist, the company currently has contracts with two Medicaid managed care organizations and two commercial insurers.
The full palliative care team includes a physician, a nurse, a social worker, a community health worker, a chaplain, and a care coordinator. Initial visits are almost always conducted in person and can include only the physician or a combination of team members, said Dr. Fratkin. Almost all subsequent visits are held virtually, and teams meet weekly to discuss individual patient needs and refine treatment plans.
To facilitate a virtual visit, Dr. Fratkin uses a web-based video conferencing tool that patients install on their computer or other device. At the time of a scheduled meeting, they receive an invitation by email and click on a link to enter the virtual exam room.
“We think of the virtual visit as the default,” said Dr. Fratkin. “When clinical presence is needed for an exam, we send one of our nurses, or if patients need help with the technology, we send one of our community health workers.”
Some patients, particularly elderly patients who are not used to using technology, are at first resistant to the idea of a virtual visit, he conceded. “But once we get started, the technology tends to disappear and we can have a very meaningful encounter without all the gravitas of a hospital or medical setting,” he said. “The biggest hurdle is getting people to have that first experience, but most appreciate being able to stay in their own home environment.”
Resolution Care receives a monthly per-member fee from insurers to provide this care to eligible patients, said Dr. Fratkin. Key to the practice's success is being located in California—the only state to have passed a law mandating home-based access to palliative care services for Medicaid patients. The law applies to patients with functional impairment from heart failure, chronic obstructive pulmonary disease, end-stage liver disease, or late-stage cancer.
Resolution Care also partners with several rural community hospitals in its service area and provides team-based inpatient consultation via videoconferencing technology.
“We offer an extra level of support for hospitalists and other providers at rural hospitals,” said Dr. Fratkin. “Our specialists help them create effective discharge plans focused on improving overall quality of life and helping patients navigate the health care system.”
At the University of Alabama at Birmingham (UAB), researchers are launching a grant-funded program testing delivery of palliative care services via telehealth to three rural hospitals in Aiken, S.C., Alexander City, Ala., and Picayune, Miss. The program plans to treat about 350 patients by partnering palliative care specialists from other parts of the states with the clinicians caring for the patients at the participating hospitals.
“Hospitalists often have to treat and discharge patients within 72 hours, making it very difficult to take the time to discuss the benefits of palliative care,” said study investigator Marie Bakitas, DNSc, professor of nursing and codirector of the UAB's Center for Palliative and Supportive Care. “Instead, patients nearing the end of life are often referred to the nearest academic medical center and end up dying far from home in a strange environment.”
She and her colleagues hope to interrupt that cycle. For the five-year study, care coordinators at participating hospitals will identify patients who could potentially benefit from palliative care, and then schedule videoconference consultations with local clinicians and the remote palliative care specialists. Researchers plan to track patients over the course of the study to measure the effects of palliative care on their symptoms, quality of life, and resource use compared with a control group.
“Palliative care is a void in many rural communities like ours,” said Michele Goldhagen, MD, hospitalist and chief medical officer at participating hospital Russell Medical Center in Alexander City. “People here know about hospice, but they often do not understand how palliative care is different or how it could help improve their quality of life.”
To participate in consultations, palliative care specialists at UAB had to become credentialed telespecialists on Russell Medical Center's staff, said Dr. Goldhagen.
“Our hope is that this study will demonstrate a clear need for this type of service in our community,” she said. “We have already invested in other teleintensivists, such as pulmonology, and palliative care is better suited to telehealth than many other specialties because of its focus on the visual, face-to-face encounter.”
Challenges, barriers
Although there is growing demand to extend palliative care expertise and training to rural hospitals, practical barriers remain, said Dr. Meier. For example, virtual visits do not allow for actually touching the patient.
“There's a lot to be said for laying on of hands—ideally, teams can do at least one in-person visit with a complete physical so that other team members have access to that documentation,” she said. “You can substitute for physical presence pretty well once patients learn how to use the technology. It's not perfect but much better than nothing for many patients.”
On the payment side, the success of practices such as Resolution Care suggests that telehealth can be both cost-effective and potentially better for patients' overall quality of life. However, many patients still lack access because telemedicine visits for palliative care are not yet covered by Medicare.
“The saddest part for me is that we don't have access to many elderly patients because they're not covered under Medicaid or a private plan,” said Dr. Fratkin. “We tried accepting more of these patients for our first three years, but it became a really substantial threat to the survival of our organization, and we had to shift our attention to patients who have a benefit through their health plan.”
Dr. Meier hopes that an increasing number of payers will see the benefits of this model of care.
“When you have large populations of seriously ill patients in rural areas with poor access to services, you can either pay for them to get to the nearest tertiary center or invest in telehealth,” she said. “Increasingly, insurers are buying into telehealth because it's both dramatically less expensive and more convenient for patients.”