Blog Post

CV providers are referring to palliative care less often—how can you reverse the trend?

September 24, 2019

    Health systems face more pressure than ever to improve quality and cut costs. However, the adoption of palliative care, long shown to be an effective means of improving long-term patient outcomes, actually seems to be falling in CV service lines: A study recently published in JAMA shows that the proportion of cardiologists referring patients for palliative care between 2015 and 2017 dropped by 6.5% to a mere 10.5%, and that referrals for CV patients lagged behind those for patients with other diseases. As the push to value-based care accelerates, the CV service line needs a course correction. Here's why palliative care should be a priority at your program—and how to incorporate it into daily CV care.

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    Benefits of palliative care not yet leading to widespread adoption

    Despite its growing prominence in health systems across the past few years, palliative care continues to suffer from the misconception that it is synonymous with end-of-life hospice. In fact, however, the defining goals of palliative care—including preventing and relieving of suffering and symptoms, enhancing quality of life, incorporating shared decision-making, providing psychological and spiritual care, and planning for end-of-life care—are compatible with earlier stages of illness.

    Given the high proportion of CV patients with chronic diseases, palliative care can be applied broadly across the service line to improve quality and lower cost. For example, a 2017 study showed that palliative care for patients with advanced heart failure (AHF) boosted quality of life scores by more than nine points. With these kinds of results, it's no surprise that one of CMS' NCD requirements for VAD delivery is the incorporation of palliative care.

    Yet despite its benefits, palliative care remains underutilized in CV patients. According to the National Palliative Care Registry (NPCR), only 14% of palliative care patients had a primary cardiac diagnosis, which does not align with the high rate of CV disease. Moreover, although the American Heart Association (AHA) has endorsed integration of palliative care into the early care of all patients with advanced heart disease, it did not provide or endorse specific recommendations for how to integrate elements of palliative care into the CV service line.

    That said, CV leaders have several opportunities to integrate palliative care into their programs, and should employ three strategies to do so.

    1. Educate physicians and patients

      According to the NPCR, only 3% of inpatient palliative care consults were referred by cardiologists, potentially indicating a lack of familiarity with the palliative resources available to them. Similarly, patients may be hesitant to access palliative care simply because they don't understand what it entails.

      Both care providers and patients stand to benefit from enhanced, targeted education to ensure that they are aware of the benefits of palliative care. Fortunately, informational resources exist to facilitate this sort of education, such as handouts for patients and families, or community forums for providers.

    2. Involve palliative care early in disease trajectory

      The JAMA study found that a significant portion of CV patients referred to palliative care were already bedbound with advanced stages of heart disease at the time of their referral, which may point to the misconception that palliative care is only a late-stage option. However, palliative care can be crucial earlier in the care process, when patients may be struggling with setting care goals, making important treatment decisions, or managing symptoms. Indeed, a next-generation CV program will include palliative care at the earliest stages of care, particularly for chronic conditions like heart failure.

      Instituting mechanisms to facilitate consults to the palliative care team or embedding a palliative care specialist in the CV care team, as Cleveland Clinic did in its outpatient HF clinic, may help ensure that patients are receiving the full extent of resources as early as their initial diagnosis.

    3. Triage palliative care resources efficiently
    4. In some cases, it may be necessary to carefully triage patients to ensure that palliative care resources are being used efficiently. Several progressive institutions have developed a tier system in which patients with the greatest palliative care needs are seen by palliative care specialists. For example, Providence Heart and Vascular Institute-Oregon flagged HF patients at high risk of 30-day readmission for palliative care consults, which helped boost utilization of the specialists. Similarly, Henry Mayo Newhall Memorial Hospital prioritizes patients for palliative care consults based on condition. Alternatively, other institutions integrate elements of palliative care through training primary care physicians or cardiologists. This requires building an understanding with your hospital's palliative care program, and offering education to all affected physicians. These conversations typically begin with a meeting between the palliative care and CV programs.

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