Making the Case for Inpatient Palliative Care

Advice and Observations from Daniel Cox, MD, Director of Palliative Care Service, Ventura County Medical Center

• Data tracking is helpful — know your penetrance in the hospital in terms of number of patients seen annually in ICU, emergency department, and acute units, as well as the hospital payer mix.
• If, like us, you do not have the ability to look at cost and revenue data for the hospital, use published data to inform your proposal. CHCF has generated a slide deck that highlights published evidence of cost savings from palliative care interventions based on appropriate de-escalation of care, less resource utilization, and shorter length of stay. It was helpful to connect with the C-suite over the fact that, even though we are not in a capitated system of payment for our patients, there are still cost savings, as the reimbursement for ICU from public insurers is lower than the cost of care.
• You can use data from the literature to create a model with estimated cost savings per patient and your actual volume of patients to generate an estimate of hospital savings annually. For us, this number was much larger than our ask. Be explicit that with more FTE, you could save even more!
• It is useful to pull together stories from the front lines to show how palliative care provides better patient care and also benefits the hospital. We highlighted patients that had been in the hospital months and who would have remained hospitalized if not for PC team intervention.
• An additional win-win connection with the C-suite is available if you discuss how you serve your colleagues by reducing burnout, highlighting emotionally how important that is.
• Consider organizing your presentation into PC impact on patient care, on helping your colleagues (burnout prevention and the cost of this), and finally on how you help the hospital’s bottom line.
• Compare your service to others in the area. We have some neighboring hospitals who had more robust PC teams, and I reached out to them and was able to get some data regarding their FTE and their volume. I used this data to show that we were understaffed/underfunded. This resonated with our leaders.
• Keep in-person meetings with the C-suite brief and make it easy for those you present to, to bring your ask forward to others. Our meeting was with CMO and CEO, with whom I had already established good relationships. The slide deck took 30 minutes to go through. I had electronic and paper copies of seminal journal articles that described cost savings from inpatient palliative care that I distributed at the conclusion of talk. The CEO stated that he really appreciated the focus on the finances and the articles, because it would make his job much easier when he went to the CFO.

Advice and Observations from Carin van Zyl, MD, FACEP, Service Chief, Adult and Pediatric Palliative Medicine LAC+USC Medical Center

• Get to know your C-suite. Invite them to lunch and do a lot of listening.
• It’s good to be ready with a broad vision sketch to pitch, or a personal story to share. It’s very helpful to know the health system pain points.
• I was really surprised that our data didn’t influence decision-making about investing in our service in the ways I thought it would. What I learned is they expect that palliative care makes everything better, so it’s not a surprise when you bring data showing how much better patient outcomes are when PC is involved. What they wanted to know was how to have a robust PC service at a low cost. I still have not figured this out.
• Think about advocating for multiple disciplines when you’re trying to build a service line. If, for instance, a social worker can address some core patient issues better than a physician could, don’t be scared to pitch that. It’s cheaper and actually meets the need better. I got better at letting go of the idea that only adding physicians or nurse practitioners would expand capacity.
• Know your comparators. Develop regional friendships with “like hospitals” in your area, so that when you are confronted with a question or a problem, you know how your team compares and what other people are doing to address that issue. Don’t reinvent the wheel.
• Be patient but persistent. County bureaucracy is its own marvelous and maddening animal. Learn how often and how hard to “check in.”
• Use the professional, polished resources from places like CAPC or CHCF. A templated deck that asks all the right questions and frames the responses in C-suite language is so valuable.

Advice and Observations from Katherine Yu, MD, Director of Palliative Care, Olive View-UCLA Medical Center; Clinical Professor of Medicine, David Geffen School of Medicine at UCLA

• At minimum, the palliative care team must have a provider (who also must champion the service regularly), a social worker, a chaplain and/or access to supportive counseling, and a service coordinator (usually a LVN or RN) who keeps the team cohesive.
• Get as many of the team members as possible trained in core elements of palliative medicine/care before you launch your service, and encourage individual team members to get certified.
• Getting the C-suite to buy in to the value of palliative care is critical in terms of resources and support, but it’s also really important to have support from other hospital leaders like the director of social work and the supervisor of chaplaincy (since you’ll want those disciplines on the palliative care team), and other departmental leaders (like physical therapy / occupational therapy, respiratory, pharmacy, etc.), so you can include their staff in palliative care interventions on an ad hoc basis (even if they are not permanent members of the team).
• Collaborate closely with divisions that see lots of patients who would benefit from palliative care (oncology, gyn/onc, pulmonary/ICU) — these divisions then become advocates for the palliative care program.
• Even with regular communication between team members, a weekly in-person interdisciplinary round is a must to discuss challenging patients, any need for changes in the operations of the team, and most importantly, to reflect on and reconnect to your larger goals and mission. As the service leader, call out instances when a team member does a good job, especially if that work is acknowledged by patients, families, or other staff. Make sure respective supervisors (social work, chaplaincy, pharmacy, etc.) are made aware of positive feedback from patients and staff received for specific team members.