5. Standards and Measures

In contrast to home health or hospice, there are no universally adopted minimum standards or measures for home-based palliative care (HBPC) across payer types. As HBPC has become more prevalent, the absence of universal and enforced minimum standards has led to significant variation in nearly every aspect of HBPC delivery. Variations include differences in eligibility criteria, care team composition, required services, payment models, and provider qualifications. Given the variation in the type of care being delivered, it is not surprising that there is also wide variation in measures used to assess key care processes and outcomes.

Although allowing for flexibility and innovation is important in a new clinical area like HBPC, stakeholders report that the current degree of variation is impeding scaling efforts and threatening quality of care. The absence of minimum standards and measures and the resulting variation has created these challenges:

• Payer reluctance. Variations in HBPC models can lead to variations in costs and outcomes, which can create uncertainty for payers and can make HBPC seem like a risky investment.
• Risk of scaling ineffective models. Absent minimum standards, payers may contract for and providers may offer palliative care services that lack core elements of interdisciplinary, comprehensive PC or that include providers with little to no training in the field. Although these services may be less costly to deliver, they are also less likely to generate good outcomes. Poor outcomes resulting from substandard care models can create the misconception that palliative care is ineffective.
• Inefficient operations. HBPC providers often manage multiple contracts with varying eligibility criteria, service models, reimbursement mechanisms, payment amounts, and measures used to assess performance. This variation creates enormous operational challenges and makes it difficult to sustain HBPC as a viable line of business.
• Underuse of services. Clinicians’ uncertainty about eligibility criteria, types of services, and quality of services can create reluctance to refer patients to HBPC.

“The one thing that we still need to do . . . is reduce the variability of palliative care. I wish I could say that palliative care consults or that interactions with palliative care teams were standardized and that everybody got the best care possible.”

—Matthew Gonzales, MD, FAAHPM, Associate Vice President, Chief Medical and Operations Officer, Providence Institute for Human Caring

Action: Refine, endorse, and adopt minimum standards and measures until federal or state mandates are put in place.

Federal and state regulations applicable to all payers and providers would be the most certain means of achieving universal adoption of minimum standards and measures. However, the prospect of this scenario occurring in the near future seems unlikely. Instead, payers and providers, who stand to benefit from minimum standards and measures, can collaborate with policymakers and researchers to set these standards and measures.

Stakeholders can build on the minimum standards previously developed by the California Department of Health Care Services (DHCS) and the California Advanced Illness Collaborative (CAIC). DHCS has already defined a minimum set of Medi-Cal standards for eligibility criteria, services, and provider qualifications. In a related but distinct endeavor, CAIC has released voluntary standards that go beyond the DHCS standards by including guidance across payer type and addressing quality measurement and payment model selection.

DHCS and CAIC’s minimum standards provide a beneficial starting point in creating universal minimum standards for all payer types. These standards can be further refined based on current practices and new insights gained since their inception, including:

• Recent descriptions of the minimum essential elements (PDF) of palliative care and quality measures presented by the National Coalition for Hospice and Palliative Care.
• Insights from plans and providers engaging in the delivery of home-based palliative care since DHCS set its minimum.
• Lessons learned from an evaluation of the CAIC standards.

The refined minimum standards could incorporate:

• Expanded eligibility criteria, required services, and minimum provider qualifications.
• Guidance about the best payment models, including the role of bundled payment.
• Specific measures.

“Too many service groups offer PC, but there are no rules, policies, standards, and measures to clarify the benefit to the patient and insurer/payer.”

—Coalition for Compassionate Care of California 2023, Annual Summit participant, health plan worker

Action: Monitor adherence to minimum standards and the use of specified measures.

Once refined minimum standards have been developed, users should actively track adherence to the standards and measures. Addressing compliance with standards that deal with the composition of the interdisciplinary team, team member competencies, or similar care structures can be done through the service design, benefit design, and contracting processes. Assessing the adequacy of care plans, the proper involvement of different team members, and similar processes can be achieved through record reviews and audits.

Absent state or federal regulations mandating reporting to a central regulatory body, plans and providers must enforce the use of measures specified in the standards within their specific organizations and areas of influence. The evaluation of the CAIC standards found that variation in measurement persisted, even among sites adhering to other aspects of the standards. Reducing this variation in measurement practices and promoting minimal measurement can be achieved more effectively by limiting the number of measures and discouraging customization by payers and providers.

Using the Palliative Care Quality Collaborative (PCQC), a national palliative care quality registry, is one way to ensure consistent tracking in a benchmarking environment that promotes quality palliative care. Several managed care plans require contracted providers to participate in the PCQC, providing plans with easy access to a common set of measures that can be compared at the provider, regional, and plan levels.

Actions for Stakeholders

Learn more about each action (PDF), including how all stakeholders can commit to this opportunity.

For full source information, see California’s Palliative Care Evolution — Opportunities to Further Advance Palliative Care in California (PDF).