Scaling Palliative Care Requires Adherence to Best Practices

We’ve come a long way in the past 20 years, evidencing how the specialty of palliative care saves money, improves quality of life, produces quality outcomes, and enhances provider satisfaction—all key elements of Quadruple Aim goals that are intended to provide a compass for high-quality health care.^1-4

Tina Basenese, MA, APN, ACHPN

Oncologists have demonstrated proven leadership advancing standardized best practices for palliative care in cancer care. For example, the American Society of Clinical Oncology recommends practices implement comprehensive, wraparound specialty palliative care programs,⁵ and OneOncology’s Pharmacy and Therapeutics Committee convenes palliative care specialty physicians from across its network to share evidenced-based strategies that have helped other private practices advance palliative programs.

With federal requirements in the Merit-based Incentive Payment System that tie quality measures to proven palliative care outcomes,⁶ commercial payers are also recognizing the value of palliative care and are beginning to implement programs.⁷

The good news is that palliative care is finally beginning to establish itself as a stand-alone specialty, one not seen as synonymous with hospice. This shift could allow palliative care to scale, enhancing the patient experience and reducing costs nationwide. However, this will require that payers recognize and use the specialty’s best practices. Only when palliative care is delivered correctly can this specialty reach its potential.

An important milestone came January 1, 2024, when a new add-on code took effect for reimbursement for complex Medicare patient visits, including palliative care. The code G2211, is to be used by primary care and specialty providers who are expected to provide longitudinal care to the patient, according to information from the American Association of Professional Coders.⁸

Having patients map out their wishes through advance directives is an important metric, but it’s not the goal of palliative care, nor is it the only way to measure whether a program works. Rather, comprehensive palliative care must be truly patient centered. This requires building trust and training palliative care specialists in a manner similar to other subspecialties to create and scale processes that are infused with a culture of communication.

More Than an Advance Directive

Consider my patient who was in her 30s and was 30 weeks pregnant when diagnosed with a stage 4 cancer. She was referred by her oncologist to in-office palliative care to assist with an intractable cough with hemoptysis, dyspnea, fatigue, and anxiety. I worked closely with the patient over the next month and got her cough under control prior to delivery of a healthy baby boy. After giving birth, the patient began to experience back pain and insomnia, along with fatigue and a managed cough. I continued to work closely with her over the next month, alongside her oncologist, and the patient experienced a notable improvement in all symptoms.

At our telehealth appointment in early August, she reported feeling much better; her imaging showed a significant response to treatment and she was thrilled. Her hair was growing back, her fatigue finally abated, and she was feeling encouraged. Although she always had a very positive attitude, this was different. She was hopeful and motivated. She talked about her son with such joy and was hoping for a continued response from her treatment so she would live “a long life with her family.” Discussing advance planning was certainly in the care plan, but I could not bear to bring up advance care planning with her during that visit—or any day before that, in fact. Although, when she was so sick early on, it was vital to have a plan in case things turned for the worse quickly, my experience told me it would not be right to do it then. There would time for that discussion later.

The day after that appointment, I saw a consultation note in the patient’s chart. Unbeknownst to me, her insurance company had scheduled a palliative care home visit with her. The last line in the chart made my heart drop: “Educate on the possible need for hospice in the future.”It wasn’t what she needed at that time. That was their plan? Nothing else? Just educate on hospice? This patient had other palliative care needs now. The insurance company didn’t follow best practices for our specialty. They seemed myopically focused on securing an advance directive.

6 Keys to Palliative Care

To advance and scale the palliative care specialty and build patient trust that palliative care isn’t just hospice care in sheep’s clothing, payers should utilize the following best practices to build programs that are truly patient centric and will lower costs.

Collaborate with the patient’s primary provider. Before a consultative visit is scheduled, collaborate with your patient’s primary care provider. The patient trusts their doctor. If the doctor embraces palliative care, the patient will trust the specialty more. You may also learn about potentially overlapping services, as in the case I’ve described. Collaboration with the palliative care specialist from the practice would have been the best care.

Know your patient through longitudinal relationships. Palliative care isn’t a one-and-done service where the outcome comes after a single visit. Talking about serious illness and how patients can make better choices that enhance their health and save the insurance company money takes time and trust. Commit to building relationships with patients.

Make communication with the oncologist part of the workflow. Communicate back with the patient’s provider every time about the visit. All palliative care measures must be in the electronic medical record and at the oncologist’s fingertips.

Build patient-focused goals. Use a strong relationship with the patient to work toward their goals. Otherwise, palliative care will appear to be pressure to agree to hospice.

Embrace full access, not advance planning palliative care. Care delivery cannot focus solely on medical aspects and ignore the psychosocial factors. You must be ready to deal with the entire person. You can’t treat a patient’s symptoms and leave them in their house without services and be surprised when the patient returns to the hospital. This will happen.

Train all providers to understand palliative care to do this work. Enhancing the primary palliative skills for all providers is imperative. There will never be enough palliative care specialists to manage the complex needs of all seriously ill patients, so training physicians to assess, refer, and treat will enhance how the specialty drives toward quadruple AIM goals.

A Patient-Centered Approach

Real palliative care must be done side by side with specialists and primary care physicians. Recognizing and acting on the nuances to any patient’s care are more likely to occur when you have a relationship with the patient—and that’s what specialty care at community oncology practices is all about. If the goal is only to get an advance directive, it belies the comprehensive, patient-centered care that defines the palliative care specialty.

Palliative care requires investment, so every patient can have the opportunity to utilize these services throughout the entire course of their care. There is a short-term cost involved both in time and money, but short-term investments yield long-term results, which is the goal of providing better patient care at reduced costs, with better patient and provider experiences.

Author Information

Tina Basenese, MA, APN, ACHPN, is a palliative care specialist with Astera Cancer Care, part of the OneOncology network. She is a board member of the New Jersey Palliative Care Advanced Practice Nurse Consortium and a member of the Northern New Jersey Chapter of the Hospice and Palliative Nurses Association, the National Hospice and Palliative Nurses Association, the Organization of Nurse Leaders of New Jersey, and the American Society of Clinical Oncology.

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