This article is sponsored by Axxess. This article is based on a Palliative Care conference Q&A with Tina Taylor, Vice President of Palliative Care Compassus and Christina Andrews, Director of Professional Services at Axxess. The Q&A took place on April 27, 2022. The discussion has been edited for length and clarity.
Hospice News: We have Tina Taylor and we also have Christina Andrews here today. Can you each introduce yourselves from your experience in palliative care, and walk us through what each of your roles are?
Tina Taylor: I’m Tina Taylor, vice president of palliative care at Compassus. I am responsible for our national palliative care programs across the nation. I am an acute care and adult and geriatric certified nurse practitioner. I also carry the hybrid crown of an MBA, and I don’t know if that’s a blessing or a curse, [laughs] to be clinical and operational. I’ve sat very heavily in the operational side of palliative care for about the past 15 years. Setting up programs, operationalizing them efficiently, and making them sustainable and sophisticated.
Thanks for sharing. Christina?
Christina Andrews: I’m Christina Andrews, the director of professional services at Axxess. I’ve had a very interesting career path, but to keep it short and sweet, I had the opportunity to be a growth leader within the palliative care service line, in addition to hospice and home health. Also, as an operator, I helped to operationalize programs within three different states. As a consultant with Simione, prior to them becoming SimiTree, I worked very closely with palliative care clients, as it relates to their growth strategy. Now I am with Axxess, and I help not only our organization internally scale, but I help our clients scale through the use of our technology.
Thank you each for being with us today. A lot of our questions focus on the demand and the opportunity for palliative care. Where do you see the needle resting in terms of the demand for palliative care? We’ve explored it a little bit, but let’s expand some more. Where do you see that heading, now versus in the future?
Taylor: Yes, I think, especially with what we’re facing, as we know, the pandemic and health inequities, there’s a huge demand for palliative care. If you think about it, I think our statistics show that in the next 20 years, our over age 65 generation will go from 50,000,000 to 100,000,000. If you think about that in terms of the elderly population and the population that’s up and coming, with the disability, chronic illness, and serious illness that affects them, there’s definitely going to be a huge need for palliative care.
Andrews: Yes, I would layer into that, as it relates to that Silver Tsunami, that it’s approaching us. We have 10,000 Americans becoming Medicare-eligible per day. Our baby boomers are around 77, and they’re approaching that average hospice age, which is 83. Then if we think about the adherence to discharge instructions, I think I read the other day on LinkedIn, it was from Trella, that 1.1 million home health individuals that said, “Please enter into home health,” didn’t adhere to those instructions. Over 100,000 who were given instructions to enter into the skilled nursing environment didn’t adhere to it. I believe it’s like 1 in 10 for hospice.
When we put all of those factors together, that Silver Tsunami approaching us, baby boomers, we have a supply versus demand mismatch, and palliative can really be that bridge to solve for that gap, starting today versus later. Especially when we take into consideration the disparity that we’re going to have for hospice specialists in the future. The need is around 24K, so we need that service line starting today, so we can set the stage for the future.
Yes, I’m glad you brought that up because we’re going to revisit that staffing question in a minute, but, before we go to that, we’ve talked about the public health emergency and how it’s on that horizon of ending. As far as the pandemic impacting the demand growth trajectory for community-based palliative care, that’s really what I wanted to touch on with you.
Andrews: The growth demand. I think the first thing that really comes to mind is looking at the community in which y’all are thinking about serving, the community that you are serving, and really doing a needs assessment. That needs assessment is going to help you, as an organization, uncover that unmet need. Based upon that unmet need, then you’re able to design the palliative care program to meet that unmet need, which then translates into a value proposition. When you take that value proposition to your key stakeholders in the communities that you serve, and say, “Listen, this is what I’m seeing, not only from claims data, but also from the demographic data. This is why we need to launch a palliative care service line within this community, and this is why we want to be your provider of choice.” Creating excitement, maybe a sexiness, around the demand of how we need to serve this patient population is crucial.
Taylor: Yes, I think, too, in light of the pandemic, number one, we’ve seen healthcare providers that cannot meet the demands of their patients, so who do they rely on? They rely on the palliative care providers, not only to come in and have their back, but to have difficult conversations for a population that is already chronically ill, that is being affected by a pandemic that is just making them significantly more sick.
I think that we have an opportunity between what palliative care accomplishes through our goals-of-care conversations, trying to reduce utilization, allowing people to have their needs met at home, and being experts at those conversations to come in early, especially in a population where they’re already affected by chronic illness but they’re also being affected by a pandemic.
Andrews: Yes, and that’s actually a really good point, the need that’s being met at home. We conducted a study and three out of four individuals said they really wish they would’ve had services in their own home, instead of that hospital setting. That pandemic, in essence, was like a fog that was lifted, and so, after time, we were able to really, I’m going to use the term again, ‘bring sexy back’ to care in the home, you know, care at home industry. They want to be able to age in place there, and we’ve been able to show that we can offer multiple multidisciplinary services within that setting, with ease, especially through technology.
It really illuminated that growing demand that may be under the radar before the pandemic.
Taylor: I think, as a hospice provider, hospices are now starting to think of their patients more upstream. They’re seeing the length of stay falling off because of the pandemic, so they really are focusing their efforts on those more upstream patients to get them in that care system sooner for serious illness and chronic illness to make that hospice transition when it’s appropriate.
With the length of stay being something that could flag regulatory attention, that palliative care builds that bridge like you had said and mentioned. Interesting point so far. I want to talk a little bit more about strategies that providers can ensure to make sure that these programs are financially stable. We’ve covered a lot of bases as far as lack of reimbursement. Want to discuss some of those strategies that each of you would have some suggestions you would give to others in the room looking to do that and make those palliative care programs sustainable.
Taylor: Yes, and that’s always a tough question. I always come with the mantra, which I’m sure we’ve all heard in this room, “If you’ve seen one palliative care program, you’ve seen one palliative care program.” Financially sustainable palliative care programs, especially as a hospice provider, we’re all kind of sitting in that Medicare part B space right now, and we’re sitting in that fee for service space. I think operational efficiency in that fee for service space has to take precedent. You have to set up strategies to evaluate your barriers, evaluate your programs, evaluate what you’re doing to ensure that you have financial sustainability.
I think, also, that we have to look into risk-sharing agreements. We have to look into value-based space to really see the outcomes that we really need to see with patients, but to also make our programs financially sustainable. I think we also have to realize that palliative care in itself is not the upfront, if you will, financial model. You also have to think about care navigation. You have to think about care transitions. Those are a huge part of palliative care and should be embedded in your palliative care process, not only for patient care, but also for financial sustainability. Palliative care in itself is not a financial vehicle, but when you think about it in terms of those extra strategies, it makes it a financially viable system of patient care.
Andrews: That loss leader strategy, and the right level of care at the right time. In my consulting experiences, one of the things that we assessed was the length of stay on palliative services, especially when the organization had a hospice service line. Those patients are eligible for that hospice benefit. Someone mentioned it earlier, it gives us the opportunity to start having the conversation sooner.
It goes from “We want all of this” down to “Now, we want this.” No one should ever say that they’re ready for hospice. Who wants to say they’re ready for hospice? The right level of care at the right time, it’s the right thing to do for the patient. It’s fiscally responsible for the organization as a whole. I would also, again, lean back into that needs assessment for the market. That really will help you to determine what you’re looking at, as it relates to demographics, poverty levels, your major insurances within the community.
Then claims data. Someone talked about claims data earlier today. It’s extremely crucial because that’s really going to help you paint the picture of, “What type of referral base can I anticipate from my stakeholders?” Then based upon that referral base, what conversion rate do I need to equate to patient days which would then lead into a census. We were actually talking earlier, that we need to begin to create a pathway of data so we can take it to the table to say “this” is what we need to change, especially within the MA plans. This is the data. This is the outcome. This is how we’re going to save you cost, but we have to begin to build that together.
It’s important to identify the patient population and then identify what operational depth you need. Is that demand for care rising, and you’ve mentioned that the expectation of those specialists coming into the field is way lower than the demand. As far as staffing pressures, healthcare and limited options for reimbursement, how can providers meet that demand, with that pool of resources that they have?
Andrews: Again, it’s that mismatch of supply versus demand. It starts with employee engagement. When you think about the essence of your palliative care brand, what is your mission, what is your vision, how does that equate to culture, and how are you going to attract a person to your why?
Taylor: One palliative care program is one palliative care program.
Andrews: Why would they want to choose your palliative care program? What makes the compensation package look different to them? We were talking earlier a couple of organizations in North Carolina are actually putting in the application process, “Sign up to become a certified nursing assistant. We’ll pay six to seven weeks for you to go get certified then you can join our organization.” At “Hello,” they’re attracting talent. At “Hello,” they’re saying we want to invest in you, so we can retain you and to keep you, so that employee experience starts at application through exit. Then what does that engagement look like? Psychological safety, because you have to get a litmus of what’s creating burnout. Right now, we have 8 in 10 of our employees, 8 out of 10 employees, are experiencing burnout daily, so they’re 2.6 more times likely to be looking for a job while we’re all sitting here in this room. We’re not going to be able to outpace the demand, but we have to think differently about how our organizations are going to attract and retain the top talent to help them serve that gap.
Even a lot of the culture and benefits are tough to offer. There’s a lot of different pieces to that puzzle. Do you have any thoughts to add?
Taylor: I think it’s important to realize, too, I work in an organization where we have multiple lines of business. We have hospice, we have palliative care, we have home health, we have infusion. I think we assume because we have this overabundance of resources, that we can just plug in a resource and expect to get the same outcomes. Just for lack of a better term, I have a person, I have a body. I need it.
That isn’t necessarily going to give you quality of care or financial sustainability in palliative care. It’s important to understand that your staff are educated in what they’re doing and that they know the reason why they’re doing it. That is what appeals to them. I think, too, that it’s very important to rely on technology. We are in a very much huge labor shortage that I think is affecting us all, even if we have this overabundance of resources; it’s still affecting us.
We have to get it right. We have to invest in technology, and we have to get it right at the outset so that clinicians and our resources are not sitting there spending an hour on documentation, but they are doing what they should be doing at the top of their licensure or the top of their scope and not necessarily just assuming that they can walk into that situation and feel comfortable or optimizing that practice.
Creating those operational efficiencies.
Taylor: Absolutely.
Andrews: Thinking about technology, what role does technology use for your organizations to help you scale talent? If you have a continuum of care, and if you’re going to pull resources, does your technology allow for onboarding? Does it allow for training? Is it going to train the staff transitioning from home health into that palliative service line on what palliative care is, or hospice? What is hospice? Then is it also going to provide training on why am I using an EMR to do what for my role? Does the technology enable you to train on the industry, to train on the solution, to ensure that you’re getting them to the top of their license, whatever that looks like, so they can launch with confidence, because that confidence, as we know, patients and families see when they walk into those homes. Technology at scale can do a lot of things.
Taylor: Don’t assume that your palliative care programs all run the same. We have many people that are running inpatient, community, clinic-based. How you operationalize those efficiently is very different. I think we all sometimes work under the assumption that palliative care is palliative care, and, yes, palliative care is palliative care, but it can also be very different from an operational perspective, depending on how you’re practicing it and delivering it.
Andrews: Does your technology provider allow control flexibility, meaning that you can turn a toggle, and now you’re providing inpatient palliative care, you can switch the toggle this way, and now you’re providing home-based palliative care or clinic-based care? Does your solution meet your current model? Will it meet your current model, or maybe models?
I think we’re going to switch gears a little bit to some of the marketing tactics, and I feel like this is your area of expertise, Christina, as far as what can strengthen those streams of referrals for palliative care.
Andrews: It’s about identifying what your brand is because it needs to speak the essence of your palliative care brand. Especially if you have a continuum of care, you don’t want your palliative care brand to look just like your hospice brand, because then that could be a barrier to entry. You don’t want your palliative care brand to look like your home health brand because then that could be confusing. What level of care am I looking for right now?
Once you identify your brand identity, then you need to move on to your messaging, so I’m going to lean back to that needs assessment, and I’ll just drop a line here. The National Hospice and Palliative Care Organization [NHPCO] has a great Palliative Care playbook that has really detailed needs assessment information. That can really help you back into that value proposition aspect. This is what you’re going to use to scream from the mountains to your stakeholders. “This is how I’m solving for those unmet needs.” Your rehospitalization within 30 days, same condition. Freeing up ICU beds, reducing ER visits, improving throughput time for the emergency room. Mortality rates, we know hospital systems love a high percentage there, right? No. How do we help with that? Once you identify those pain points, now, we think about our physician community. The claims data also will identify when the physician saw their patients last? When did they issue that referral to home health or Hospice? When did that patient enter into that service line? You can immediately see that gap of time. Every day that a patient does not receive care is a day that they’re winding back up in that hospital system, so you can identify underutilization of services.
That value proposition and the key messaging, then helps you to translate into your overall marketing strategy, sales and marketing strategy, so claims data. With all the claims data, you understand your pain points, you understand the value propositions, what do you do with it? Well, now you develop territories. You hire sales CEOs, to manage those territories. What does that look like? It can look like 50, it can look like 75. Then you also have to have productivity measurements around managing that territory.
At the end of the day, it’s their job to speak your brand, to educate the community on how you’re solving for those pain points, to bring in those referrals to equate to patient days that add up to an average daily census. The technique and concept is crucial, even within palliative care, because you have to be available to your stakeholders who you’ve already introduced your brand to, created excitement for, so then they have ownership in helping you to succeed. I would break it up to those three buckets. Branding, key messaging, your marketing and sales strategy with claims data, and then your concepts and techniques, which is territory development and then the productivity of driving sales results.
Taylor: To piggyback on Christina’s value proposition, it’s important to ask the question of, “What are you trying to solve for?” I think that when we go out and we market, we say, “We know what palliative care does, and this is what we’re going to do” but that may not necessarily be what that organization or that person needs. You may have a high hospitalization rate over here. You may have high utilization over here. If you’re pitching yourself or you’re talking about palliative care from a blanket statement of, “We know this is what it does,” that’s not necessarily speaking to the specifics of what that organization may need. Ask the tough questions, ask the questions about, “What are you trying to solve for?” “What area are you needing support in to be able to address that?”
I think, too, data. Data is huge. Data is a huge marketing tool that we can use. Show your outcomes, show your metrics. It’s extremely important to show the great work that you’re doing in palliative care. Show your hospitalizations, your decreasing utilization, your shared savings. I think that’s an area too, that we need to improve on, is those areas of measurement and those areas of standardization and those KPIs not only show great patient outcomes and what’s happening in the palliative care space, but it’s also a huge marketing strategy to show how your organization is really doing in that space as well.
Andrews: And making a difference.
Taylor: Absolutely.
Andrews: And how it compares. Something that to avoid or not to avoid, is many organizations forget about weekend sales. Healthcare never stops, if you haven’t thought about layering in that weekend sales plan, it’s crucial. I think I heard, the other day, it is called pajama plan, and I get it. I mean, being able to drink your coffee, maybe do your yoga, make a couple of phone calls, but, at the end of the day, health care is a face-to-face component. You can make the phone calls on Thursdays and Fridays and say, “Hey, it’s Christina. I’m going to be there at this time. I’m going to help you transition those patients.” That can be a huge differentiator to your competitor down the street because they’re probably going to stay in their pajamas and not leave their house.
Right. I think in terms of marketing tactics, too, we’ve discussed a lack of a standardized definition for palliative care. Just defining it in your tactics, I think, would probably be, to your point, a part of that too.
Taylor: Absolutely.
Absolutely. We have some good questions from our audiences. One of them is, “Is there an appetite for palliative care services provided by hospice organizations, outside of being a feeder for hospice? I think we discussed this bit about upstream. Any thoughts from either of you on that one?
Taylor: I think so. I mean, what we’re seeing in the landscape, and knowing where palliative care is going, I think we recognize that hospices are saying, “We’re seeing people trail off from hospice. They’re not having that length of stay that they were. We’re seeing hospice numbers dip.” We have a pandemic coming in, there is an absolute need for palliative care. We know everything that we do and in every specialty. I think that more hospice providers are recognizing that, especially with the landscape and all of the other factors that are driving that, very much still.
Andrews: Again, somebody had mentioned this earlier, live discharges. Folks do graduate from hospice, so being able to have that plan B, “Let’s put you back onto palliative services until you’re eligible again.”
Be that bridge that you spoke about earlier. I’m glad you brought up the length of stay because that’s one of our questions that came in too. “Does the average length of stay increase for a hospice patient if they come from a palliative care program? If so, just what would be the average number of days?” is the question.
Andrews: That’s a really great question. I don’t have that statistic off the back of my head, but I would anticipate, just based upon my experience of working with a hospice agency that also had palliative care. By having those conversations sooner, you’re identifying eligibility more towards that six months. I mean, they paid for their six-month benefit. Let’s help them get connected to it. Whether you’re artificial intelligence or your technology company that you’re using, or it’s just that clinician, the nurse practitioner, or the provider him or herself, identifying when is the appropriate time to have this conversation based upon the disease trajectory? I would anticipate the length of stay for hospice growing. If you have internal processes in place, workflow processes in place to help streamline that and optimize it.
Taylor: If you think about palliative care getting in there, the average length of stay in palliative care is seven to eight months. The more we get in there earlier and start having conversations about goals of care with these patients, when it’s time for hospice, they’re ready for hospice. They go sooner, they are not hesitant, they know exactly what their disease trajectory looks like, and they’re entering hospice earlier.
We also know people have an increased quality of life and live longer the sooner they go to hospice. The sooner that palliative care gets on board, we do see the outcome that they go to hospice sooner. They have less hesitation about going to hospice.
Andrews: I would also say that it could help with burnout because now your hospice clinical team has more time with that patient and family. They’re not having to manage such a short length of stay in that turnover.
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