This article is brought to you by nVoq. This article is based on a Q&A session with Jason Banks, Senior Director of Post Acute Sales at nVoq, during the Hospice News Palliative Care Conference. The Q&A took place on April 27, 2022. The discussion has been edited for length and clarity.
Hospice News: Jason has an incredible background in post-acute care that we’re going to talk about today. Your experience in palliative care has been at an organization that has a number of multi-sites and various approaches. Talk to us about that.
Banks: I ran a hospice and palliative care. When I started in the area, we had 600 palliative care patients, that grew to 1,200 pretty quickly. We had a multimodal approach, meaning we serviced in the hospital, in senior living settings, and in the home. We had two palliative care clinics. We had 30 providers providing palliative care across the city of Chicago and suburbs.
We had approximately six or seven full time employees support staff for them. I know one of the questions that came about was: how do you handle credentialing? How do you handle billing? We had a team in the area of four FTEs just for scheduling alone. We had another two and a half to three FTEs associated with credentialing and billing specifically. They had sort of a crossover effect.
When you talk about credentialing, there are two different types of credentialing. There’s credentialing with the payer, but then there’s also credentialing with the facility that you’re going to be providing care in. You’ve got to consider both of those when you’re standing up a new palliative care program. For those of you that are wondering, “Well, how do we go get those resources?” There are a number of organizations, some of them are in the room that actually provide those as a service.
You don’t necessarily have to go out and find somebody who’s experienced in palliative care credentialing. Good luck, by the way, if you’re looking for that sort of experience. They’re not widely available. Like I said, there’s a number of organizations out there that do that as a service and can do it at scale. As you grow, you can look at onboarding those individuals.
My next question for you is after you’ve gotten past that startup mode, what happens next with capturing more market share with referral sources and then working with payers to ramp up to outside of that startup mode?
A lot of that has to do with relationships. Do you have the connections with the hospitals or the senior living facilities or the physicians who are going to ultimately refer those patients to your practice? It really boils down to understanding those audiences because they do have different value propositions and bringing data to the table.
That was one area that we struggled with. I think a lot of, particularly traditional home health and hospice organizations, struggle with bringing real quality data to the table with their referral sources. Again, the data is going to be much, much different depending on the referral source. A hospital is going to want to know how quickly you are going to get this patient out of bed.
Whereas, a senior living facility is going to want to know how to mitigate risk. That’s the big draw for them. Whereas, physicians are ultimately going to want to know if you are taking good care of the patient and family who I’ve known for 30 years and how can you prove that to me? You have to really know your audience. It takes understanding and having those relationships and then being able to bring data to the table that’s meaningful to them. If I brought the table data to a hospital administrator that talked about me managing their risk in a hospital environment, they’d be like, “I’m not really interested in that.”
They want to know how quickly we can have a goals-of-care conversation with the patient. Our physicians are generally uncomfortable with those conversations. What multimodal approach can you bring to the table? Do you have a doctor and a social worker that can work on, for instance, Medicaid eligibility. We have a patient who really has nowhere to go after the hospital. We understand you have a physician or an NP or a PA that can go have that end-of-life conversation that can manage symptoms, but what are you doing beyond that for things like Social Determinants of Health [SDOH] and getting that patient to a safe place?
In terms of systems and data as you referenced a minute ago, can you talk to us about your experience? There are so many challenges to having those conversations with senior living and hospitals. Can you talk to us about how you see the world change from the homegrown to where we are today.
I think as palliative care continues to grow, we need to shine a light on this because it’s needed not just for extended end-of-life care, which is how we’ve traditionally known it in the home health and hospice world, to true chronic disease management and holistic care of members, patients, residents in their homes.
We used a proprietary EHR system. We had a proprietary reporting system. Not ideal. There are lots of good systems and more coming online every day to be able to help manage palliative care programs, but not just the EHR. I think that’s a small part of it.
When I look at them compared to traditional home health and hospice, they’re leveraging technologies in ways that I don’t see traditional home health and hospice doing. For instance, they have robust workforce management systems that let them know everything from optimal route optimization to GPS tracking, to instant communication, to patient engagement tools that they’re using and all across the board. I’m with a company that sells speech recognition.
Instead of providers, clinicians typing their notes, they speak them. They do it much faster, they do it at a higher quality. Those tools are pretty commonplace outside of traditional home health and hospice. They’re not new. They’re just new to this industry. Those are the types of things that I think organizations that are used to providing either a per diem hospice-type service or even a palliative care fee-for-service type model, they struggle with: how do I leverage the technology to actually help enable better outcomes for the patients and families?
Technology is a big part of innovation as we all know. Talk to us about some of the other areas of innovation that you see fueling this market today.
There’s obviously multimodal organizations across the country. We’re seeing more different types of models. We’re seeing organizations that are partnering with primary physicians or have primary physicians of their own. As an organization, we were trying to ultimately work with the payers, but there’s some intermediary steps to there.
If you look at Oak Street Health, VillageMD, GenCare, those are types of primary practice organizations. They actually don’t have palliative care specialists within their organizations today. I see home health, hospice organizations, or independent palliative care organizations starting to work with those primary practices as a way to infuse everything from goals-of-care conversations to addressing mental health, spiritual needs, emotional needs of that patient as a part of the overall care continuum.
Tell us about some of the pitfalls that you had when growing the palliative care practice.
Well, I don’t think we have enough time, but I probably made every mistake in the book. Some of the big ones were really not thinking through the whole billing process. Many of you know, I don’t need to tell you. You’re living this every day. Providing palliative care in the home at a break-even point, it’s nearly impossible. That’s the reality.
We were very successful at providing it at a break-even point in a skilled nursing or a senior living setting or even a hospital setting, but we struggled in the home setting, and a lot of that actually had to do with: how do we educate our clinicians and treat them more like we do in hospice? We started having palliative care IDGs, where we would have our medical director sit in on case management and case conferences to understand “should we have actually coded this differently than we did?”
The patient is really acute, and we’re providing some pretty intensive care, yet we coded it as a follow-up visit or some sort of advance care or goals-of-care conversation. We started getting really sophisticated as we grew the palliative care program. The other thing that I learned was you can grow too big too quickly. As I said, we started with about 700 palliative care patients when I got there, grew to 1200, I shrunk it to 750. Why?
We had patients going and dying on palliative care or they were moving into a different hospice even though we were providing palliative care. Why? Because we weren’t seeing them often enough, we weren’t having those frequent touch bases with the patient and family. Another thing that, I’ll just say, I had this mistake on the hospice side, I didn’t treat hospice patients much differently either.
I had my standard two times a week nursing, one time a week social worker, once a month chaplain, once every other month music therapist. We have to get away from that in both palliative care and hospice care.
It was really unfair to our NPs and our physicians that we weren’t assisting them in supporting the emotional needs, the religious concerns that the patient and family might have, or spiritual needs that they might have. I think we’re coming a long way. My story is that in addition to running a hospice and palliative care program, I have a child with a chronic disease. In 2015, he was diagnosed with Crohn’s, had three surgeries pretty quickly within a year and was homebound for about nine months.
I looked for a palliative care program that served pediatrics in my area. I couldn’t find one. They didn’t exist. I thought, “How could this be?” We have a lot of physical needs with him, but we also have a lot of psychosocial support needs and emotional needs and mental health needs and all those sorts of things. There was absolutely nothing, so I want to thank those of you in the room that are on a mission to bring palliative care to the forefront, because it is so needed in this country, and not just for geriatric patients, it’s absolutely needed for geriatric patients, but we need it for pediatric patients, we need it for chronic disease management, we need it for everybody in this country. It needs to be a part of what we do.
I’m hoping eventually the term palliative will go away, and it’ll just be care. Same thing with SDOH, which is sort of a weird term, but it’s all the things that determine the patient’s outcome anyway. Hopefully, those things are just part of providing care.
nVoq Incorporated provides a HIPAA and PCI-DSS compliant, cloud-based speech recognition platform supporting a wide variety of healthcare delivery scenarios including post-acute care with an emphasis on home health care and hospice. To learn more visit: https://sayit.nvoq.com/.
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