Palliative Care in Hospice: Program Development and Financial Considerations

1. National Hospice and Palliative Care OrganizationPalliative Care Resource SeriesShould our Hospice Provide Palliative Care?Conducting an Organizational AssessmentGretchen Brown, MSWformer President and CEO of Hospice of the Bluegrass

2. Objectives • Discuss the potential benefits to a hospice offered by a palliative care program • Describe the importance of a needs assessment when considering palliative care services • Compare potential palliative care program models • Identify financial considerations when implementing a palliative care program

3. Hospice as the Palliative Care Provider • A successful palliative care program depends upon • Sufficient community need • Adequate financial resources • Ample clinical resources and clinical expertise

4. Hospice- the Ideal Providerof Palliative Care Hospices: • Understand palliative care concepts and interventions • Are experienced at discussing pt/family end-of-life wishes • Can describe advantages and disadvantages of treatments • Are certified and specially trained to care for patients who are appropriate for palliative care • Have experience providing care in a variety of settings

5. Is Palliative Care Needed in my Community? • Conduct a Needs Assessment/Feasibility Study • Type of palliative care program • Adequate staffing and financial resources • Internal staff discussion of pros and cons • Involve administrative and clinical leaders • Medical director • Financial staff • Representatives from partners or potential partners • Form a planning committee!

6. Program Development • Develop a list of community programs already offering services • Investigate potential program models • Determine capacity and resources of hospice provider • Examine financial and budget issues required to develop, grow and sustain • Uncover additional helpful resources

7. Program Development: Community Programs History • Competitors were few when hospices began to offer palliative care • Hospitals provided in acute care setting Today • Palliative care offered by most hospitals • Some hospitals provide palliative home care • Many nursing homes, home health agencies, private physician practices, insurance companies provide palliative care

8. Program Development: Community Programs Potential patients • PACE programs • Transitions programs • Private or institutional case management programs

9. Program Development: Community Programs • Evaluate available services • History • Competence • Community reputation • Location • Is there a gap in services? Where?

10. Program Development: Investigate Program Models • Inpatient acute care model using one to a full range of palliative providers in a hospital setting • Outpatient model providing services in a skilled nursing facility or patients’ homes • Independent clinic or palliative medicine practice

11. Program Development: Determine Capacity • Identify knowledge deficits • Advanced clinical knowledge of aggressive treatment for diseases • Understanding of operation, regulations and goals of different settings • Home • Hospital • Nursing facility • Long term acute hospital • Challenge of 24 hour on call services

12. Financial Considerations:Hospices • Palliative care programs – decrease cost of care for medically complex patients • Payment to hospice organization is limited • Medicare Part B and insurance payment • Physicians and nurse practitioners • Other billable physician extenders • Social workers in some outpatient settings • Hospitals, insurers and managed care may have special arrangements

13. Financial Considerations: Healthcare Systems • Hospices within healthcare systems – easier time funding palliative care program • In system ‘credit’ for cost savings/cost avoidance to overall system can fund new program Examples: • Kaiser – multi-state entity serves as healthcare provider and insurer • Mt. Carmel in Columbus, Ohio • Sharp system in San Diego, California • Sutter in the Bay area • Comprehensive systems in which health system owns the continuum of acute care, home care and hospice

14. Financial Considerations: Collaborative Models • Health system funds palliative care • Supports large percentage or entire program • Offers subsidies for visits • Collects for billable service or allows hospice to do so (subtracting the billings) • Healthcare system may provide non billable staff or contract from the hospice • Can be effective for acute care, home and clinic models • Can break even! • Example- Hospice of the Bluegrass

15. Financial Considerations: Fee for Service, Per Diem or Capitated Rate • Partner with large insurance company • Insurance company agrees to pay for service, per diem or capitated rate for home based palliative care • Creative Programs – Hospice of Michigan’s @HOMe • Developed contracts supplying adequate number of patients and payment • System for evaluating the savings generated to health system

16. Financial Considerations: Fee for Service, Per Diem or Capitated Rate • Medical homes • Contract with hospice organizations to provide palliative care to patients where capitated rates are common. • Stable base for homecare program • Dependable partner – insurer, union, Accountable Care Organization • Income and referral stream

17. Hospice as the Palliative Care Provider • Most difficult model to sustain • Inpatient programs may breakeven if enough consults • Travel for homecare erodes limited patient billing

18. Analyzing the Demand and Making the Budget • Knowledge about patients or beneficiaries • Value of cost avoidance • palliative care program reduces costs • prevents inpatient admissions • leads to earlier hospice admissions • Volume of services to estimate income and expenses

19. Analyzing the Demand and Making the Budget To do’s for the hospice • Obtain Medicare Part B billing number • Billable practitioners need to be credentialed with other payers (Medicare and private insurers) • Payments vary • Setting where service is rendered • Type of service • Type of visit • Duration of visit • Number and type of each visit will need to be estimated

20. Analyzing the Demand and Making the Budget To Do’s for the Hospice • Calculate difference between cost and income • Initially bottom line will be negative! • Determine if deficit will be offset by • Service differentiation • Partnership or customer development • Potential for additional patients • Potential for increased length of stay

21. Other Considerations Pilot programs • Help determine potential success of new program • Inpatient program – one service or one floor in a facility for specified time • Home based program – 20 referrals from hospital or insurer • Help staff understand strengths and weaknesses • Reveal unexpected challenges and opportunities

22. Other Considerations State and federal regulations • Impact how program is organized and implemented • Legal advice from healthcare attorney early in planning process • Hospice can benefit from partner’s legal counsel – should also have its own

23. Other Considerations Additional resources • Philanthropic support for startup and ongoing • Family • Healthcare systems • Community foundations • Educational resources • Hired consultant

24. Conclusion • Hospice organizations are ideal palliative care providers and partners • Education and planning are key to deciding to provide palliative care • Only if quality services can be provided at a cost that does not negatively affect the hospice!