Palliative care is a term used daily in both professional conversation as well as in the consumer media. Often palliative care is identified as an independent entity-a type of healthcare distinct from other points on the continuum of care. In reality, palliative care is an addition to traditional care. It is a specialty still trying to find a reliable business model.

"Palliative care, and the medical sub-specialty of palliative medicine, is specialized medical care for people living with serious illness. It focuses on providing relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of palliative care doctors, nurses, social workers and others who work together with a patient's other doctors to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment." (Center to Advance Palliative Care, 2016)

Unlike a hospital, skilled facility, home care, hospice, or even office-based care, palliative care is designed to be delivered anywhere a patient is located particularly as patients' transition across settings. This makes payment for services complicated, as there isn't a dedicated palliative care benefit in the Medicare program.

Hospitals often provide inpatient palliative care to help manage complex patients and reduce readmissions, but home care agencies face a more difficult payment structure, as palliation doesn't fit easily within the current reimbursement structure. Many patients may have a skilled need (symptom management) but are not homebound as they continue to make outpatient visits for curative treatments. They don't qualify for the Medicare Home Health benefit and are not interested in choosing the Medicare Hospice benefit. These patients often need expert, supportive care to maximize quality of life. They are the exact population that palliative care specialists can help the most. Providing palliative care at home can help avoid hospitalizations and other complications resulting in extremely cost-effective care when it's available and accessible.

Payment barriers limit home care providers and stifle innovation. However, opportunities exist, and some home-based palliative care programs are growing and expanding by developing creative models of care and partnering with other providers in the community including local hospices.

Many states are also realizing the value of Palliative Care and have either passed legislation or have proposed legislation to facilitate access to care for those with advanced illness.

California's Medicaid Program (Medi-Cal) has approved reimbursement for palliative care-a move that is encouraging innovation. Although California has not finalized their Palliative Care Policy or defined the reimbursement structure, home care agencies in the state are leading the country in palliative initiatives. Providers are developing new programs and working directly with their local Medi-Cal health plans for contractual consideration.

Palliative Care programs are built on the needs and resources of their unique communities. Two Palliative Care Models of Care in California are described below. One program was started 10 years ago and the other is in its pilot phase.

Visiting Nurse and Hospice Care of Santa Barbara

In 2006, the Visiting Nurse and Hospice Care of Santa Barbara's (VNHCSB) Palliative Care Program began as a consultation service at Cottage Hospital in partnership with other community healthcare organizations. The model expanded to include an outpatient clinic at the local cancer center and home-based services with Visiting Nurse and Hospice Care. The same team that consults with the patient in the inpatient setting also sees the patient at the clinic and in the home. This integrated model supports continuity and improves coordination of care across the continuum.

The team is comprised of physicians, registered nurses, a nurse practitioner, and social worker. They work with an average of 80 patients a day, helping them to stay focused on the quality of their lives as they manage their health needs. The coordination and stability offered by VNHCSB's Palliative Care program provides patients and families support and guidance as their goals change and the care provided shifts from the hospital to home, and often to hospice care.

To support continued program growth and expansion, innovative technology such as telehealth (currently used in their Home Health program) is being considered to improve access to rural patients and provide clinical efficiencies. Each year the VNHCSB contributes resources to support the palliative program as part of their ongoing mission to deliver comprehensive healthcare to all of Santa Barbara County. This is done in collaboration with other community healthcare providers.

Hospice of Santa Cruz County

Alternatively, in 2014 the Hospice of Santa Cruz County recognized a significant lack of available palliative care and initiated a home-based program. At the time, only one healthcare organization was providing palliative care in the community, and services were limited to patients within one healthcare group. Hospice of Santa Cruz County sought to support more people with serious illness and developed a palliative care pilot program for patients at home and in one local skilled nursing facility.

Members of the team consisted of the Hospice Medical Director, a Nurse Practitioner, a program coordinator, two part-time social workers, and an RN Case Manager. The Palliative Care team reached out to community providers to develop collaborative partnerships in an effort to identify opportunities for improved patient outcomes and financial support for the program. After writing a detailed proposal and presenting the business case for palliative care, the hospice's board approved funding as did the local Independent Practice Association with capitated contracts. A Per Member Per Month (PMPM) rate was negotiated with consideration for incentives once the program had established metrics. The medical group assigned an RN Case Manager as a point of contact and the palliative care team meets with them monthly to review outcomes and data. In addition, a shared electronic record is used to document authorization for services. Over and above the PMPM rate, additional reimbursement was anticipated for MD/NP visits billed to Medicare Part B as well as Medi-Cal healthplan contracts to offset expenses. In addition, if patients transitioned to hospice earlier and increased their length of stay, the palliative program could generate income for the hospice business line. The program continues in its pilot phase.

Both programs recognize unmet patient needs in people with serious illness and work to overcome the limits of payment structures by working with community partners. Both programs are monitoring and measuring the impact of their programs through financial, clinical, and community outcomes. And while they only represent two of the possible palliative care models that could be implemented, both programs are leading the way for home healthcare agencies to play a more integral role in palliative care.

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