Measurement and Quality
Take Action: Tips for Leveraging the 2019 State-by-State Report Card
Updated October 30, 2019 | By Maggie Rogers and Stacie Sinclair
Providing hospital palliative care services to our nation’s seriously ill patients is a critical component of quality health care. Palliative care has been shown, in multiple settings, patient populations, and disease types, to improve patient and family caregiver quality of life, strengthen communication with clinicians about preparation for what to expect, and reduce occurrence of symptom crises resulting in emergency hospitalizations. Hospitals must deliver high-quality care for their most seriously ill and complex patients while remaining financially viable, and palliative care is essential to achieving this goal. However, reliable access to these services will only be possible through concerted efforts to drive supportive public policy, ensure reliable financing, and increase professional and public awareness of palliative care and its benefits.
Recently released, the 2019 State-by-State Report Card ("Report Card") provides an analysis of whether patients living with a serious illness in the United States have access to hospitals with palliative care programs. The primary goals of the Report Card are to increase awareness and inspire action among key stakeholders, and to provide policy recommendations for state and federal policymakers, as well as the private sector including health systems, accountable care organizations, health plans, and employers.
As a palliative care champion, there are many ways to leverage the Report Card to improve access to palliative care locally and nationally. Open the Report Card and follow these three steps to take action, and make lasting change for our nation’s sickest patients:
Step 1: Interpret Your State’s Grade
The Report Card calculates the percentage of hospitals with fifty or more beds in a state that have a palliative care program, and assigns a grade based on that percentage. Grades fall into the following ranges: A: 80% or more; B: 60%-79%; C: 40%-59%; D: 20%-39%.
- If your state received an A, your state has a relatively high prevalence of hospital palliative care programs. If a hospital in your state does not offer palliative care, it is lagging behind many of the other hospitals in the state in providing this vital service. However, even in states where more than 80% of hospitals provide some level of palliative care services, variation in staff capacity to meet demand for services, and program characteristics means that not all patients living with a serious illness who would benefit from palliative care have access to it in that state, and there is room for improvement.
- If your state received a B, C, or a D, your state has a relatively low prevalence of hospital-based palliative care programs. This means that a significant percentage of hospitals have not yet established programs, and therefore, many seriously ill patients do not have access to palliative care when admitted. A hospital with an established palliative care program in a B, C, or D state is leading the way to provide high-value care to patients in need and, in some cases, may only be one out of a handful of hospitals to offer this essential service in the surrounding area.
Some additional context can be helpful in interpreting your state’s grade.
For instance, regardless of the grade, specific types of hospitals are more likely to provide palliative care. Hospitals with 300 or more beds, teaching hospitals, non-profit hospitals, and Catholic Church-operated hospitals, all have rates of palliative care above 80%. Hospitals that fall into any of these categories that do not currently offer palliative care are significantly lagging, regardless of where they are located in the United States or their state’s grade.
Step 2: Complete the Story
While the Report Card provides a critical foundation to understanding palliative care access in your state, be aware that these grades do not tell the complete story. Hospitals with fewer than fifty beds are not included in the state grade (see the table on page 38 and the section on “Hospitals with fewer than fifty beds” on page 14 in the Report Card for more information). And the Report Card does not contain information on the quality, staffing, or reach of these hospital palliative care programs. The Report Card does not include palliative care programs operating in the community, such as those providing services in clinics or office practices, in the home, or in long-term care facilities.
Therefore, it is important for palliative care champions to build on the findings of the 2019 State-by-State Report Card by locating as much of this information as you can.
You may have access to more information about palliative care in your state through a State Palliative Care Association (e.g., New York or Minnesota), State Palliative Care Advisory Council, or Comprehensive Cancer Control Program. Some states, such as Florida and California, have conducted research on local access which contain useful information and could serve as a template for other states. Collecting more information about program availability, reach, and quality will help you identify and priorities opportunities for action.
To help track the growth of palliative care and understand how palliative care programs are meeting national guidelines on programmatic and clinical quality, champions should also encourage all palliative care programs to participate in the following project:
- Palliative Care Quality Collaborative (PCQC): Launching in 2020, PCQC is a new national registry that will collect programmatic data on palliative care operations, staffing, and features. This new registry will combine the National Palliative Care Registry™ (current project of CAPC and the National Palliative Care Research Center), Mapping Community Palliative Care (current project of CAPC and the National Coalition for Hospice and Palliative Care), the Palliative Care Quality Network (PCQN), and the Global Palliative Care Quality Alliance (GPCQA). It will provide palliative care programs with reports that compare them to similar programs on structure and process, at no cost. For an additional fee, PCQC will also collect clinical patient-level data to drive quality improvement and reporting.
The findings from PCQC will provide you with better snapshots into access, availability, and quality across the continuum of care.
Step 3: Establish Goals and Take Action
The Report Card can be a catalyst for conversations about how to ensure that all patients with serious illness have access to high-quality palliative care. The Report Card includes information that is relevant to multiple audiences, ranging from hospital administrators to state health departments to federal legislators. Below are sample activities for how champions can leverage the Report Card to achieve their goals.
Goal: Drive federal support for palliative care
- Incorporate the Report Card into meetings with federal policymakers to frame the need for palliative care access in your state and nationwide.
- Identify palliative care gaps and opportunities; implement relevant recommendations from the Report Card Policy section.
How to Use the Report Card to Support Federal Policy Changes
- Given the large size of the Federal Government and diversity of actors, the Report Card breaks out these policy recommendations into two buckets – Federal Legislation (key audience: Congress) and Federal Regulation (key audiences: Centers for Medicare and Medicaid Services, National Institutes of Health, etc.). For any meeting, make sure that you match any selected policy recommendations to the appropriate audience; otherwise, those you meet with might politely nod their heads and go about their business without taking any action!
- If you meet with your Senators and/or Representative (or more likely their staffers), first take a few moments to ensure they understand what palliative care is. While many will say they know, it is important to have a clear “elevator speech” to avoid potential confusion or misperceptions. There is excellent language starting on page 4 of the Report Card defining palliative care and its positive impact on quality, cost, and patient and family satisfaction. If time allows, share a personal story.
- Second, review your state’s grade (starting on page 8), noting any changes over time. Include high-level details you learned in your “Step 2: Complete the Story” fact-finding – and if you think any progress is linked to specific actions taken by your legislators, thank them! Then note that, despite any progress, there are still patients in need of palliative care who do not have access.
- Finally, select 2-3 top recommendations (starting on page 20) that you want to focus on with your legislator. This can be based on your passion or expertise, but also try to do some homework in advance. Do they sit on a committee that focuses on workforce issues? Then select a recommendation from “Workforce” or “Clinician Skill Building.” Have they spoken in the past about the rising costs of health care or the need for accountability? Then identify a recommendation or two from “Payment” or “Quality, Standards, and Research.” Explain what the recommendation is and how it will help patients with serious illness. Offer to serve as a resource moving forward – subject matter expert, pilot site, speaker. And make sure to thank them for their commitment to improving patient quality of life!
Goal: Increase state recognition and support for palliative care
- Partner with local organizations that focus on improving care for people living with a serious illness to promote Report Card dissemination.
- Incorporate the Report Card into meetings with state policymakers (e.g., legislators, State Medicaid Directors) to frame the need for palliative care access in your state.
- Identify state-specific palliative care gaps and opportunities, implement relevant recommendations from the Report Card Policy section.
- Incorporate Report Card findings into State Palliative Care Advisory Council (or similar body) deliberations, and leverage the findings and policy recommendations to support the agenda.
How to Use the Report Card to Support State Policy Changes
State officials, including legislators, department and agency staff, and other state employees, are interested in learning about opportunities to improve quality of life and the value of health care for their residents. When meeting with your representatives or other state leaders to discuss the Report Card, several tips in the Federal box apply; i.e., explain palliative care, tell the story, do your homework to ensure you understand your audience’s priorities. In addition to highlighting your state’s grade, review how your state compares to others in your region (starting on page 10, greater detail on page 38) – in this case, a little healthy competition can be helpful!
What sets state-level meetings apart is that they provide an excellent opportunity to be specific! When you were “completing the story,” what did you learn about opportunities and barriers in your state? For instance:
- Is there a specific region in which there is concentrated need, and a new or expanded palliative care program could dramatically improve patient access?
- Does your state struggle to hire and retain palliative care specialists?
- Has there ever been a palliative care awareness campaign?
The Report Card’s state policy recommendations (starting on page 26) are broken out into “Workforce,” “Payment,” “Quality, Standards, and Research,” “Clinician Skill Building,” and “Public and Clinician Awareness.” Based on your state findings – including your knowledge of what is feasible in the local policy environment – select 2-3 top recommendations that most directly address the highest priority gaps. This section is full of examples of initiatives from other states that you can model your work on.
Goal: Launch or expand a palliative care program in a hospital or local community
- Incorporate the Report Card into meetings with administrators and program funders to provide greater context on the need that your program could fill.
How to Use the Report Card with Local Leaders and Funders
Leveraging the Report Card with your C-suite, funders, or other key stakeholders will depend on your goals – are you hoping to start a palliative care program? Grow your existing program? Support clinician skill-building? That said, the Report Card can be useful in inspiring action across these audiences because it provides context for your goals. In lower-grade states, the Report Card can create urgency because it highlights large gaps in palliative care access for patients with serious illness. For higher-grade states, there is a great opportunity to cement your reputation as a national leader.
Beyond providing context, it is worth noting that many of the recommendations in “A Call to Action” (starting on page 16) are not limited to policymakers. Health systems leaders, practices pursuing value, and funders can lend their support to advocacy efforts. There are also many opportunities to go above and beyond by adapting certain recommendations in the “State Policy” (page 26) and “Purchasers, Health Plans, and Accountable Care Organizations (ACOs)” (page 31) sections. For instance, hospital administrators can review the National Consensus Project (NCP) Clinical Practice Guidelines for Quality Palliative Care and create an organization-wide initiative to bring services into greater alignment with these. Foundations can establish grant programs to support targeted clinical training, helping to advance shared-decisionmaking and quality of life. The benefit of leaders taking independent and early action is that their efforts can help position the state for future success if any policy changes occur; and in the meantime, they are improving care for people who need it the most.
Goal: Educate all clinical staff in communication, pain and symptom management, caregiver support, and when to refer to specialty palliative care
- Review Report Card recommendations on clinician skill-building.
- Identify appropriate organization-wide training opportunities like CAPC Membership.
Do you have additional suggestions, or questions, on how to leverage the 2019 State-by-State Report Card? Email firstname.lastname@example.org to share your thoughts!
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