What Are Models for Delivering Palliative Care in Hospitals?

Introduction and Scope of the Problem

Now and for the foreseeable future, hospitals remain at the center of health care in mid- to high-income nations. In the Organisation for Economic Co-operation and Development (OECD) countries, 28% of all health care dollars are spent on inpatient services. In the United States this number is 33%. Whereas the proportion of people dying in hospitals in the United States has been declining over the past several decades (48% in 2000 to 33% in 2019) , 66% of Americans 65 years of age or older will be hospitalized at least once, and 42% will be admitted to a critical care unit in the last 6 months of life. On average, Medicare beneficiaries will spend 8.1 days in the hospital in the six months before death and 14 days in the last two years of life. Like so much of health care, hospitalization rates, particularly for the seriously ill, display regional variation, as does the likelihood of persons receiving high-intensity and burdensome hospital treatments prior to death. This chapter reviews the prevalence of inpatient palliative care programs in the United States, how value can be demonstrated for such programs, and staffing and delivery models for palliative care in the hospital setting.

Prevalence and Predictors of Hospital Palliative Care

Hospital palliative care programs have grown considerably over the past several decades in the United States. The Center to Advance Palliative Care (CAPC) and the National Palliative Care Research Center (NPCRC) have tracked the growth of palliative care in hospitals since 2001 ( Fig. 67.1 ). In their most recent report, 72% of all hospitals with more than 50 beds reported having a palliative care program. These hospitals currently serve 87% of all hospitalized patients in the United States. Ninety-four percent of hospitals with more than 300 beds have a palliative care program, whereas 36% of small hospitals (fewer than 50 beds) have a palliative care program of some type. Whereas hospitals with fewer than 50 beds make up more than two-thirds of U.S. hospitals, they account for less than 5% of all admissions (1.2 million patient admissions per year). Small hospitals are typically in rural areas, and in less populous states such as Iowa, Kansas, Montana, and the Dakotas, three-quarters or more of all hospitals have 50 or fewer beds. The small number of annual patient admissions at small hospitals and the even smaller number of admissions that could benefit from palliative care make it difficult for many of these hospitals to support full palliative care teams.

Geographic location and regional characteristics strongly influence the availability of palliative care services in the Unites States ( Fig. 67.2 ). People living with a serious illness who reside in the Northeast have access to significantly more hospital palliative care programs than those living in other regions. More than 80% of hospitals in the mid-Atlantic, East North Central, and New England regions report a palliative care team as of 2019. Conversely, only 48% and 51% of hospitals have palliative care teams in the East and West South Central regions, respectively. Access to palliative care for people living in rural America remains limited. Ninety percent of hospitals with palliative care are in urban areas, and only 17% of rural hospitals with 50 or more beds report palliative care programs.

Access to palliative care also depends on hospital characteristics. Tax status remains a strong significant predictor of the presence of a palliative care team. For-profit hospitals of any size are significantly less likely to provide palliative care services than nonprofit or public hospitals. Eighty-two percent of nonprofit hospitals, 60% of public hospitals, and only 35% of for-profit hospitals (up from 23% in 2015) report palliative care programs. Conversely, over 90% of National Cancer Institute–designated cancer centers and academic teaching hospitals have palliative care programs. Designated public and sole community provider hospitals are often the only option for people lacking health care coverage (10% of the population) or for those who are geographically isolated, yet only 40% of sole community provider hospitals had a palliative care team in 2019. Finally, of the 56 freestanding children’s hospitals with 50 or more beds in the United States, 48 (86%) reported a pediatric palliative care team, and in the Pacific region, all 11 children’s hospitals (100%) had pediatric palliative care teams as of 2019.

The Value of Palliative Care for Hospitals

It was not by chance that U.S. palliative care developed and expanded in hospitals rather than in other settings. Prior to the passage of the Affordable Care Act and its expansion of Medicare Advantage and the creation of Alternative Payment Models, the fee-for-service financing structure of health care in ambulatory care settings failed to provide support for the interdisciplinary palliative care team beyond physician reimbursement. Within hospitals, however, the demonstration of the enhanced quality provided by palliative care teams, in combination with significant cost savings to hospitals, provided a strong business case to support their development. Unlike the ambulatory care settings, hospitals receive a lump sum diagnosis-related group (DRG) payment for an episode of patient care. Thus hospitals that can enhance revenues through maximizing DRG payments, improve care efficiency, reduce length of stay and increase admissions, and reduce unnecessary spending are able to maximize their profit margins. While palliative care programs do not generate significant direct revenue, they can contribute to significant cost avoidance and savings for the hospital. Specifically, by clearly establishing patient goals of care and aligning treatments with these goals, palliative care teams are able to reduce unnecessary spending on goal discordant tests, procedures, medications, and interventions. Furthermore, by assisting with complicated transition planning for the most complex and expensive hospital patient populations, palliative care teams are able to reduce hospital length of stay and enhance hospital throughput and efficiency. Indeed, a recent meta-analysis pooling data from 6 studies of hospital palliative care consultation teams (13,318 patients of whom 93% were discharged alive) found that, irrespective of diagnosis, palliative care significantly reduced hospital costs by over $3,237 (U.S.) per hospital admission. These cost reductions were greater for those patients with four or more comorbidities than for those with two or fewer, those with cancer as compared to other diseases, and those who were seen by palliative care within the first 3 days of admission. These data, in concert with prior research drawn from U.S. hospice studies and European and Australian research on the beneficial clinical effects on patient and family outcomes of palliative care, led to the rapid growth of U.S. hospital palliative care programs depicted in Fig. 67.1 .

Delivery Models of Hospital Palliative Care