Case study at North Carolina palliative care program demonstrates how to create a financially sound model

January 7, 2013 – The authors used quality improvement and performance improvement measures to identify reasons for financial loss, and then implemented solutions.

With the population aging, it is important to have more health care programs that can treat patients who have terminal illnesses but do not need to be hospitalized and are not ready for hospice care. Palliative care programs fit this niche, and these types of inpatient hospital programs have increased rapidly across the United States. Outpatient palliative care growth has been slower, partly due to challenges for finding a successful financial model.

Researchers recently completed a case study at the Four Seasons Compassion for Life palliative care program in North Carolina. The results of the case study were published in the December issue of the Journal of Pain and Symptom Management. The DCRI’s Amy Abernethy, MD, was the senior author. The DCRI’s Arif Kamal, MD, was also an author.

The authors used quality improvement and performance improvement measures to identify reasons for financial loss, and then implemented solutions. Based on a review of the successful solutions, they then developed a sustainable and successful model of outpatient palliative care.

Four Seasons, initially a hospice organization, opened a palliative care program in 2003 that provided care in hospitals, nursing homes, assisted living facilities, patient homes, and outpatient clinics. Four Seasons was experiencing escalating financial losses for several years after opening the palliative care program.

In 2008, the Four Season’s palliative care program treated approximately 300 patients per day with 10.5 (full-time and half-time) providers and experienced a financial loss of approximately $400,000 per year. In 2011, after the quality and performance improvement initiative, the program treated more than 600 patients per day with 14 providers, and financial losses decreased by 40 percent.

The plan the researchers implemented to improve quality of care and decrease financial losses included:

  • Standardizing palliative care visits to the same length of time and including the same best practices.
  • Standardizing data collection by developing a data collection tool, which allows the practice to monitor patient symptoms, aid in advance care planning, and more. Metrics can be tracked by provider, allowing for individual mentoring for providers who are not performing at the level of their peers.
  • Making end-of-life care discussions with patients and families a standard component of care, and mentoring providers in how to conduct these important discussions.
  • Increasing referrals to the palliative care program, and educating the community and providers at local nursing homes about the benefits of palliative care.
  • Mentoring midlevel physicians, and developing a palliative care immersion course, which is required for all new physicians.
  • Increasing physician recruitment and retention by hiring local physicians, allowing them to job-share or work part time, and offering consistent education and mentoring opportunities for providers.
  • Educating providers about how to code visits based on complexity rather than duration.
  • Removing administrative tasks from physicians to maximize clinical time, and assigning this work to administrative staff instead.

The changes implemented at Four Seasons led to many positive outcomes. The number of patient visits doubled; billings per provider increased by an average of 35 percent; and all providers are now billing at an amount equal to their salary and benefits. Four Seasons and the researchers working with them have also created a Center of Excellence that offers consulting services to other palliative care programs across the country.