Background: Interdisciplinary palliative care and Medicare-certified hospice care have been proven to improve quality and decrease cost of care. Models that can be replicated to disseminate to standard community health care systems are needed.

Aim: Develop one palliative care and hospice program to serve a typical 12-hospital non-profit faith-based community health system as part of routine operations.

Methods: In 2012 a large faith-based non-profit health system of 12 hospitals with an aggregate of 2,000 beds serving a population of 3.5 million people in the State of Ohio determined it needed a program of palliative care and hospice in preparation for change to a value-driven health care market. One program, accountable to a single President was established in the home care division, along with other ‘post-acute’ programs. Hospitals purchase palliative care in a unit of a team composed of physician, nurse practitioner, social worker, chaplain, pharmacist; there is no hospital impact to FTE:Bed ratio. Management overhead costs are allocated to each hospital based on volume. The hospital-owned hospice expanded to cover all regions served by all hospitals, expanded its dedicated inpatient GIP hospice unit to 32 beds, made the unit ‘closed’ to a full-time specialist staff, changed its orientation to ‘open access’ and ensured full time specialist physician membership on all hospice teams with ability to make home visits,

Results: After 2 years of planning and piloting and 4 years of execution, $11 M in new annual spending from operations on 69 new clinical FTEs (including $800K in overhead for 6 FTE) delivers 7,500 hospital consults each year (8% of admissions, range 2-11%) with additional embedded outpatient care in cancer, heart failure, and COPD offices and new physician and NP staffing for the hospice agency. Average day of consult is 3.2 (range 1.5 to 3.9). All inpatient care is paid on DRG basis. Using CAPC method of cost avoidance, conservatively modified by OhioHealth finance to eliminate estimated labor savings and no LOS savings and including fee-for-service provider revenue yields a margin of 24%. Hospice growth from ADC of 250 to 600, with increase of median length of stay 10 days to 30 days in central region of focus and average length of stay increase from 40 days to 90 days was achieved. The electronic health record shows a 40% improvement in mean pain scores for all patients seen by palliative care receiving opioids.

Conclusion: A comprehensive program serving a typical, conservative non-profit US community health system can be successfully implemented in a revenue-neutral fashion. The key strategy to insist teams use consultation etiquette was the driver for rapid growth. The key barrier to further growth is the revenue destruction effect on a fee-for-service model of health care delivery.

Author

Charles F. von Gunten, MD, PhD
Vice President, Medical Affairs, Hospice and Palliative Care
OhioHealth
5450 Frantz Road, Suite 100
Dublin, OH 43214
(614) 533-6299