With an aging population that has more complex illness, providers, health systems, and others in non-hospital settings are struggling with how to best care for these patients. In the following interview, Dr. Kate Lally, Care New England Health System Director of Palliative Care, explains that palliative care provided throughout the care continuum can be part of the answer. Dr. Lally is faculty for the IHI Expedition: Conversation Ready: Understanding and Respecting Patients' End-of-Life Wishes.
Dr. Kate Lally explains in this video why more ACOs are focusing on palliative care
to improve care for medically complex patients while reducing costs.
How would you describe the general state of palliative care in the US today?
Palliative care is really growing in the US today. We have an aging population that has more and more complex illness. Doctors, nurses, health systems, and others are struggling with how we best care for these patients. Palliative care can be part of the answer because palliative care providers have the skills to engage with patients about what their wishes are, manage multiple problems at the same time, and aren’t afraid of handling really complex patients. A growing number of people across the health care system — from CEOs who are making funding decisions to frontline providers who are struggling with caring for these patients — are seeing how helpful palliative care can be. I feel very lucky to be part of a field that is helping more and more people in more and more ways every day.
What are the key opportunities for improving palliative care?
Much of palliative care involves specialty care providers, board-certified people like me who have done a lot of training. Geriatricians have been doing this work for a long time and social workers frequently engage with patients about what’s important to them. But there are also frontline physicians, primary care doctors, hospitalists, ER physicians, bedside nurses, and others who really want to have that basic set of palliative care skills. For example, how do you engage with a patient to help them explore what’s important to them? How do you provide good pain and symptom relief?
There are a lot of opportunities for education around that primary palliative care skill set. It’s a big priority for specialty palliative care teams, like my team, to give that information to other providers. There are not enough physicians, nurse practitioners, nurses, social workers, and others trained in palliative care to go around. Every seriously ill patient would benefit from having a multidisciplinary team focusing on symptom management and what’s important to the patient.
In my organization, we do a lot of training with residents, home care nurses, and nurses in the hospital to teach people how to engage with patients in a meaningful way so that we can spread palliative care across a hospital, across a health system, and touch so many more lives than a specialized palliative care team could.
Why is it so important to address palliative care throughout the care continuum?
Most palliative care focuses on the inpatient setting because, for patients who are critically ill, this type of care is important. However, what happens when we go outside the hospital walls? Those patients who are discharged from the hospital on palliative care versus hospice need someone in the community who can engage with them, support their family, and help them make further decisions about what’s important to them.
This is important for patient care, but it’s also important for cost reduction in a world that’s looking at shared savings models, at ACOs, at how we provide high-quality care at a lower cost. Going into the community and engaging with patients in meaningful ways becomes all the more important. Many health systems are developing their community resources, with nurses, social workers, nurse practitioners, and others going into the home, communicating with primary care physicians and other specialists to provide very complex care in the home, and helping to keep these patients out of the hospital if they don’t want to be there.
In the past year or so, there has been increasing discussion — in an article in Health Affairs, a toolkit from the Toward Accountable Care Consortium, and an article in the Journal of Palliative Medicine, for example — about how palliative care could bring value to ACOs. Would you comment on that?
As we move toward shared savings models, and look at the cost and quality of care, we need to find a better way to care for very sick patients — often at the end of their lives — who use up a lot of health care dollars. So, how do we better manage this specific group of people? That is what all ACOs — everybody who’s struggling with shared savings models and looking at quality-based care — are looking at. And this is what we already do in palliative care — we manage patients with multiple medical issues.
In the fee-for-service model, palliative care was not seen as a money-making operation. Now, however, in a time when the better care for patients – that gives them the health care they want –is actually more financially feasible, more and more health systems are making palliative care a priority.
Often when we ask, “What’s important to you?” medically complex patients will say, “I don’t want to be in the hospital.” If we can put structures in place – like providing nursing care or services like housekeeping – to help give these patients what they need in the home, it keeps them out of the hospital, which is really a win-win because that’s what patients want and it’s what hospitals want as they face penalties for readmissions. I think that is why the people who are thinking about how we pay for health care are really focusing on palliative care as at least a part of how we can manage our sickest patients.
The issue in finding a better way to care for these very sick patients, however, is that there are so few people who are trained to do it well. That’s why it’s worth looking at the people who are already doing this kind of work in your organization, for example, geriatricians, social workers, physicians, nurses, nurse practitioners, and others — how do you pull them together, and how do we get them to engage with their patients about what their wishes are? How do we use vising nurse associations to increase the services they provide for these sick patients, to help keep them out of the hospital? Look within your own organization, find the people who have these strengths, and work on training them to provide better care.
What are the advantages of providing early palliative care?
Palliative care offers so many benefits to patients. Multiple studies have shown that palliative care early in a serious diagnosis not only improves your quality of life – which seems obvious since the goal is to improve pain and symptoms – but it can actually help you live longer. Beyond that, palliative care will often help a person and their family think about what’s most important to them, and having those conversations about care early on can be so helpful.
Consider a young woman with a cancer diagnosis. She may have one set of wishes when she’s young and has young children. At that point, she may want to live as long as possible no matter what. As her children get older, as she develops more illnesses, her life may change and her wishes may change. Engaging in those conversations early and then frequently throughout your life will help your family know what’s important to you if the time ever comes that they need to make decisions for you.
What makes you so passionate about palliative care?
I’m passionate about palliative care because I’ve always loved caring for really complex patients. I was a primary care provider prior to focusing on palliative care, which I do now full time. People ask me, “Do you think the work that you do is sad?” I don’t think it’s sad at all because people are in tough situations, but I can help. When a person is sick, in pain, and struggling with a scary diagnosis, I can help them feel better. I can help them feel less alone, and let them know there are people who are going to support them through whatever they’re experiencing no matter what. That’s something I have the privilege to do.
In addition, palliative care is great because you get to work all throughout the health system. You get to have amazing interactions with patients, teach doctors and nurses, and sit at the table with people who are making decisions for your health care system, talking about how to manage the sickest of the sick and the resources needed. For all of those reasons, I love what I do.