What Are the Models for Delivering Palliative Care in the Ambulatory Practice Setting?

How Has Ambulatory Palliative Care Evolved?

Although palliative care provided in outpatient settings was once considered “a new frontier in palliative care,” the prevalence and penetration of ambulatory palliative care has grown substantially around the world over the past decade. Ambulatory palliative care originally focused on patients with cancer, where the growth in access has been significant. In the United States, 95% of National Cancer Institute (NCI)–designated cancer centers offered outpatient palliative care in 2018, as compared with 59% in 2009. Access has increased at non-NCI–designated cancer centers as well (40% offered outpatient palliative care in 2018, compared to 22% in 2009), though notably these centers remain far less likely than NCI-designated cancer centers to offer outpatient palliative care services. More recently, ambulatory palliative care practices have also expanded in many countries to treat a range of serious illnesses, including heart failure, chronic respiratory diseases, kidney disease, and neurological diseases. In addition to well-established academic outpatient services, growth has also occurred in small ambulatory palliative care services, operating independently or in affiliation with hospitals or hospice agencies.

Where Is Ambulatory Palliative Care Delivered?

Ambulatory palliative care takes place in an outpatient setting. Ambulatory palliative care practices assume some or all of the logistical and administrative challenges of running an outpatient medical practice. This means that practices need adequate clinical, administrative, and waiting room space, nursing staff, and administrative support for prior authorization, copayment processing, and billing services. Three common models to provide the necessary infrastructure are (1) a freestanding practice, (2) palliative care colocated with a non–palliative care practice (e.g., an oncology office, heart failure clinic, or primary care practice), and (3) roving palliative care clinicians who travel to the clinic where a patient is being seen by the referring physician.

A freestanding practice is able to define their environment, atmosphere, and patient flow. Palliative care teams in independent practices may be better able to prioritize the involvement of the interdisciplinary palliative care team (e.g., inclusion of social workers and chaplains). However, freestanding palliative care practices must take on all of the financial costs of running a practice, such as rent, electricity, maintenance, electronic medical record access, staffing (clerical, scheduling, and clinical), recordkeeping, and so forth.

Colocated palliative care practices are situated within the referring provider’s clinic, such as a primary care clinic or specialty practice. This potentially allows the palliative care team to be truly embedded and use many of the resources of the hosting practice, based on prearranged agreements (rooms, lights, computers, schedulers, check-in staff). The hosting practice typically is the source of the palliative care group’s referrals (or a large portion of them). Importantly, the colocation facilitates a close working relationship between the referrer and the palliative care team. This may result in a more consistent message provided for the patient and an increased likelihood that symptom management recommendations will be followed. Occasionally palliative care teams will provide specialty trained physicians and/or nurse practitioners while relying on the “home clinic’s” social workers and/or chaplains. Additionally, there may be greater ability for the palliative care team to support the primary team; this support might take the form of providing same-day or shared visits and/or providing informal advice for a patient’s care. Several studies have shown that patients with oncologists whose practice has colocated palliative care are more likely to be seen by clinicians who specialize in palliative care. One of these studies also found that sharing practice locations resulted in more timely referrals and earlier referral to hospice at the end of a patient’s life. However, as a guest or even renter in a host’s practice, the palliative care team may need to modify their own practice to be more consistent with the host practice; for example, opioid prescribing practices may differ.

Finally, some palliative care specialists go to multiple practices, acting as a roving team. This model is convenient for referring physicians and patients by making palliative care available on-site but presents significant logistical challenges for the palliative care clinicians who must travel between practices. Additional limitations of this model include the difficulty of ensuring consistent palliative care availability for each practice and logistical and billing challenges when two clinicians are seeing a patient in the same outpatient visit. Telemedicine—a visit between a remote palliative care specialist and a patient over videoconferencing technology or telephone—may provide some advantages of the roaming model without the aforementioned efficiency challenges (see Chapter 73 ).

What Are the Common Models for Delivering Ambulatory Palliative Care?

Ambulatory palliative care practices must determine the level and scope of responsibility they will take for managing their patients with serious illness. There are two common models: consultative and comanagement. In a pure consultation model, the palliative care team assesses the patient and then offers recommendations to the referring physician. In contrast, in the comanagement model, palliative care clinicians can assume primary responsibility for certain aspects of patient care, such as symptom management, while primary teams continue to manage the primary serious illness. There are advantages and disadvantages to each of these approaches.

In the consultative model, patients are seen once (or perhaps a few additional times), then implementation of the longer-term plan is left to other treating clinicians (e.g., the primary care provider, cardiologist, or oncologist). This model requires fewer resources from the palliative care team and may therefore enable clinicians to expand specialty palliative care access and reach more patients with palliative care needs. Consultative models may also facilitate palliative care teams helping to develop palliative care skills among primary clinicians. Although this model clearly helps to limit the clinical responsibility of the palliative care team in order to maximize a limited workforce, one distinct disadvantage of this model is that it does not guarantee that the referring clinician will enact the team’s treatment recommendations. This may be especially true around complex pain management issues (because of lack of knowledge, discomfort with or hesitancy to prescribe opioids), complex psychosocial care, or care from disciplines not commonly used by or available to the referring physician (such as chaplaincy).

The patient care benefits in comanagement are clear: the palliative care team implements their plans, can write prescriptions, and provides follow-up assessments, monitoring, and readjustment. This model may also allow primary care teams to focus more on managing the primary diagnosis (e.g., allowing oncologists to focus more on the patient’s cancer treatment).

Comanagement, and particularly the act of prescribing pain medications, carries a higher level of responsibility. Palliative care teams must be responsible for ongoing management of the pain medications and refills, managing side effects, and completing necessary regulatory paperwork. This requires someone to be available for around-the-clock clinical coverage, unless other arrangements are made with the patient’s referring provider. Comanagement also frequently involves longitudinal care, which may create a burgeoning practice census. In this model, it is critical that the palliative care team and the referring team are clear about who is prescribing medications for pain management in order to avoid medication errors.

Who Is Involved in Providing Ambulatory Palliative Care?

Key to the ambulatory effort is the composition of the palliative care team. While early ambulatory palliative care models focused on physicians and advanced practice providers, there is increased recognition that ambulatory palliative care should incorporate broad interdisciplinary support in the same manner as inpatient palliative care. The exact composition of the interdisciplinary team varies based on the practice setting, type of patients served, and available resources. The National Consensus Project defines high-quality palliative care teams as including physicians, nurses, social workers, and chaplains. Some ambulatory palliative care practices also include psychologists, pharmacists, dietitians, physical and rehabilitation therapists, and music and art therapists on their teams. Staffing is often shared between inpatient and outpatient palliative care. The logistics of protecting time for inpatient clinicians to staff the varying models of ambulatory clinic are complex. Specialty palliative care workforce shortages and the fee-for-service billing model pose substantial challenges to staffing ambulatory practices.

Although there are challenges to having clinicians from the same palliative care team provide inpatient and ambulatory palliative care services, there are also advantages. Close collaboration between inpatient and ambulatory palliative care clinicians may facilitate comprehensive discharge planning and enhanced continuity. Outpatient palliative care clinicians can titrate symptom management medications and/or continue goals of care conversations. Close links between services can improve administrative efficiency, through sharing of expertise and staffing. There may also be ways that the ambulatory practice can benefit from the cost-avoidance model of the inpatient service.

Clinics must decide who is on the team and also who will be in the room with patients. It is expensive to have multiple professionals seeing the patient simultaneously. Additionally, although physicians and advanced practice providers can bill for their services, other members of the team typically cannot. Additional considerations include the needs of learners, constraints on exam room space, and the risk of overwhelming the patient and/or family.

Finally, practices must develop systems to support the well-being of clinicians and administrative staff while promoting teamwork (see Chapter 80 ). The clinical work of outpatient palliative care is rewarding but also difficult. Meeting patient requests that occur outside of clinic hours (e.g., through having a call system) places additional demands on the ambulatory palliative care clinician. Each member of the palliative care team needs the ability to recover, rejuvenate, and recommit. Mourning or remembrance rituals for patients who have died, team retreats, professional psychological support, and social events are just some methods that can be used for this purpose.