Sean Morrison on the Current State of Palliative Care

Eric: Welcome to the GeriPal Podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, who is our guest today?

Alex: Today we have the Dr. Sean Morrison, who is director of the National Palliative Care Research Center and the Hertzberg Palliative Care Institute at Mount Sinai in New York. Welcome to the GeriPal Podcast, Sean.

Sean: Thanks, gentlemen. Good to be here.

Eric: And we start this off with our guest making a request to Alex for a song they’d like to hear.

Sean: Alex, could I have a song?

Alex: So I thought that in honor of you, Sean, who is a Beatles fan and made a wonderful joke about The Beatles and a group called The Beach Boys, I believe. They’re some sort of historical group that was important in U.S. history, I understand.

Sean: You have a very good memory, Dr. Smith.

Alex: (laughs) At the recent Foley retreat, Sean was introducing Vince Mor, who is an esteemed palliative care researcher in his own right, and said, “Whenever Vince Mor publishes something, I feel like Brian Wilson (who is the front man for The Beach Boys) did when the Beatles published Sergeant Pepper’s Lonely Hearts Club Band.”

Eric: So let’s hear a little of it!

Alex: So this is “When I’m 64” from that album. One of the few songs I can play from this concept album.

Alex sings “When I’m 64” by The Beatles.

Eric: That was great.

Alex: So we should dive into this report here, Sean. It’s sponsored, as I understand it, by both by the National Palliative Care Research Center and CAPC, is that correct? The Center to Advance Palliative Care?

Sean: That is correct. Absolutely.

Eric: And the report is titled, “How We Work: Trends and Insights in Hospital Palliative Care.” We’ll have a link to the report on the GeriPal website. And really we’re looking at trends between 2009 and 2015. Sean, do you want to give us, like, a brief overview about the report?

Sean: Sure, so this is a report that is based upon the National Palliative Care Registry, which is a joint product of the National Palliative Care Research Center and The Center to Advance Palliative Care, which is a voluntary database where programs throughout the United States input information about the structures and processes associated with palliative care delivery. And we’ve been collecting data over the past 10 years and this report really tracks some of the metrics associated with the growth of hospital palliative care in the United States.

Eric: You know, one of the first big findings that I saw was is that currently in 2015, 4.8% of all hospital admissions received a palliative care consult. And I was just impressed by that number, and per the report that number as increased from 2.7 of all admissions in 2009 to 4.8. Are there other things from this report that really stood out for you when you put it together?

Sean: I think there are a couple things beside that. Obviously as you know the growth in palliative care has been rather rapid in terms of the number of programs since, oh, 2005. And accompanying that has been a growth in the penetration of those programs into various hospitals. So first of all, I think the biggest finding is that palliative care teams on average are seeing almost 5% of hospitalized patients, but some teams are seeing up to 15 or 16%. And the right number is probably somewhere between seven and a half to 15 depending upon the makeup of the hospital.

I think the other thing that we’ve seen that is equally impressive is the growth of teams that now support a full interdisciplinary team of a physician, nurse practitioner or registered nurse, chaplain, or social worker – and social worker, sorry. And that that was a very small group of programs many years ago but is now increasing also, rather exponentially.

Alex: It’s interesting there are a number of glass half-full glass half-empty story lines in here, aren’t there? And I think there’s tremendous, I was really impressed with the growth of interdisciplinary teams, and yet … I’m flipping through trying to find it. Somewhere in here it says something like, “Of those teams,” yeah, here it is, “Who are without a complete interdisciplinary team, 70% have no chaplain.” So there’s been tremendous growth particularly in the nurses as part of the interdisciplinary team, but there’s still a lot of opportunity to increase chaplaincy support for palliative care teams.

Sean: Oh I agree completely, Eric. And I think one of the things we’ve seen is, exactly as you’ve pointed out, is that we’ve seen really a tremendous growth in the number of advance practice nurses that are in the field. We’ve also seen a growth, you know, an accompanying growth in terms in of the number of physicians. But where we, as you said, we still have a lot of room for improvement is both in social work and in chaplaincy. And I, it’s perhaps not surprising that those are the two disciplines where they can’t bill for their services. And I think a large part of the lack of growth in those two areas is because of finances.

Eric: Are there ways that we could address that?

Sean: I think there are a number of way that are addressing that. First of all, I think The National Consensus Project has pretty clearly stated that palliative care needs to be delivered by an interdisciplinary team that encompasses those four core disciplines: medicine, nursing, social work, and chaplaincy. That certainly not all patients need all of those team members, but all of those team members need to be available.

I think the moving that sort of idealistic consensus-driven document into actual practice is going to require things like accreditation. The Joint Commission now, in terms of their advance certification program, you can’t have a palliative care team unless you have those four components and be certified by the Joint Commission. That’s a step that we need to move forward with. That this is part, that we move palliative care from accreditation to certification.

The other piece that I think will help drive this is research. What clearly has helped promote the growth of palliative care in this country has been research that has demonstrated that it contributes to value. That it improves both patient quality of life and family well-being, at the same time doing so in a cost-effective manner. And I think when we look at, particularly spirituality, there is increasing evidence of the importance of spirituality to seriously ill patients and their families. There are beginning to be data about the impact of poorly addressed spiritual distress in that population, both on patient and on family well-being. And indeed some small data on it’s effects on increasing health care costs. So I think we really do need concrete evidence-based data, which I think will exist and can be done, on the impact on both psychological and spiritual well-being on value in health care.

Alex: That’s interesting. I think of my own clinical experience, anecdotally, sometimes there are days when we have no chaplaincy support or social work support. And we can do the consult but the quality of the consult is not as good. And I should also mention that, you know, a social worker could do the consult by themselves or the chaplain could the consult by themselves but the quality of the consult is not as good.

Sean: I couldn’t agree more. We rely on the support of our social workers and our chaplains, both in terms of our patient care, but also in terms of the care of our interdisciplinary team. And that I don’t think we could function as a palliative care institute without their input.

Eric: So the other thing I noticed is the demand for palliative care clinician seems really high. I read that in the report, 64% of palliative care programs are seeking additional staff. I think the nice part of where these trends are going, it sounds like the vast majority, 82% of physicians are board certified in palliative care, but when you get to advance practice nurses it’s about half, registered nurses about half, social workers 30%, and chaplains 11. Part of that is that the chaplain’s and social worker’s certifications occurred within the last decade, but the advance practice nurses, they’ve had certifications well before even the physicians. But we’re still not seeing a high percent of them being board certified.

Sean: Yeah, I mean I think you also put your finger on one of the major challenges for the field. Is that we don’t have a workforce now that meets the current need for palliative care specialists across all four disciplines. And it is pretty clear that even though we are dramatically increasing the number of all four core disciplines who are entering the field of palliative care and becoming, as you said, board certified. We are still not going to meet the need. So what are we do about that?

And I think there are three key solutions, or three solutions that we need to think about. The first is we need to think about insuring that every clinician who cares for a person with serious illness has the core knowledge and skills to provide primary palliative care. So that we can use palliative care specialists truly as specialists. So that’s the first thing that has to happen.

The second thing that has to happen is, I think we need to begin to use the data that we have to target populations that most benefit from palliative care services. And I hate to say the work triage, but it’s really about matching patient need with the knowledge and skills that specialist care provides.

And then I think the third issue, and to me the most important issue, and this is, I think one represented by your blog, is that we need to get beyond the specialty silos that quote, unquote are palliative care and geriatrics, and really need to think about the care of complex, seriously older adults from a population health perspective. And that as long as we continue to think about these within silos of geriatrics, palliative care, palliative medicine, cardiology, we’re not going to be addressing the needs of this population. And so the idea that focusing two fields, geriatrics and palliative care, both on the needs of this population, targeting the high-risk individuals for specialist level care and expanding primary palliative care and geriatrics so that we raise the floor or the basement of care for this population of patients.

Alex: That’s music to our ears! (laughs) So you know, I wanted to move back to an earlier point, you said that the appropriate … targeting palliative care referrals is an important step, that was point number two. And that earlier you said that the right proportion of hospitalized patients who receive a palliative care consult is probably between somewhere between 7 and 15%. I’m interested in how you came up with that number.

Sean: I knew you were going to ask me that. So it, I must admit, it’s a ballpark estimate.

And it’s an estimate based largely on the work of both your group out at UCSF, we call that Mount Sinai West by the way, and the work of Amy Kelly here at Mount Sinai who have begun to look at the size of the population that has one or more serious medical illnesses, an element of functional impairment, and or cognitive impairment superimposed on that. Because I think that is the complex target population that palliative care geriatrics needs to address. And when you look at those estimates, it ranges from somewhere from about 5% of the overall Medicare population, slightly lower in a Medicaid population, and obviously higher in a dual-eligible population. So I think, sort of, the bottom line is that 5%, but the reality is in hospitals you tend to get a higher population or percentage of patients with serious illness being hospitalized.

And so I think that number goes up, and it probably goes up to about 15, 16% and I say that because if we look at palliative care programs that have been in business for a long time, have a pretty extensive program, have good penetration in the hospital, they’re seeing about 15 to 16% of the hospitalized population. So that’s where my number, that’s where my estimate comes from.

Eric: That’s great. There’s also an interesting piece about readmissions and that 18, 14% of palliative care patients were readmitted to the hospital in 30 days of discharge. And that, by way of reference, all-cause readmissions were about 18%. And that, the palliative care patients we’re seeing are likely more complex, more disabled, more cognitively impaired, more frail, more seriously ill than the all-cause. So that 14% is probably, you know, the 18% benchmark is probably not appropriate comparison for that 14%, so actually, we’re probably doing pretty well at preventing readmission, which is actually a huge issue for hospitals and health systems.

Sean: I couldn’t agree more, particularly since hospitals are now being penalized for unwanted and unnecessary readmissions. And I think what this speaks to is the ability of palliative care teams to identify patient’s goals, to match treatments to those goals, and then to create an effective and safe discharge plan that allows patients to be cared for in the setting of their choice. And for most people that is not the hospital, so providing that added layer of support when people leave the hospital and go home, I think helps tremendously in terms of preventing those unnecessary and unwanted readmissions, for example, for a pain crisis, for a breathlessness crisis, because you ran out of medications, because there wasn’t enough support in the home to take care of somebody with Alzheimer’s disease and related functional impairment. So I’m not actually not terribly surprised by that finding, although some of my colleagues are

Alex: So I got a question. You know, seven years from now when we’re revisiting this in our next podcast together, Sean, what do you think the trends are going to look like then?

Sean: That’s a really good question. So let me step back and sort of take it from, you know, sort of the beginning of our report and just sort of walk through what I would consider to be the big changes or the big trends. I am cautiously optimistic that what we’re going to see is the complete interdisciplinary team moving from 44% up until well over two-thirds of hospitals. I think there’s always going to be hospitals that can’t support a full team, largely because of their size. That, you know, if you’re a small hospital you may not have that type of patient volume, but I would like to see the complete interdisciplinary team number move above 50% and into the 60s and I think that … I think that will happen. I think that’s a realistic goal for us.

I also think that consistent with what we’ve seen from 2009 to 2015 that palliative, the number of patients who are going to be dying in the hospital, I think, I hope to see decline as we do a better job of allowing people to be cared for in the setting of their choice. I think the number of people we see with cancer is probably gonna, probably going to stay around 20, 25% because that’s where, that’s the number of deaths that occur because of cancer in this country. And clearly what I would really like to see is that number of programs who have a board certified physician or advance practice nurse in palliative medicine be at 100% or at least 95%. I can’t think of any other specialty where we would accept the fact that, for example somebody is practicing cardiology works in a cardiovascular institute but is not board certified in cardiovascular medicine. So that’s number two, is the full interdisciplinary team.

And then I think the other big area where I would like to see growth, and I expect to see growth is in the penetration rate. That, again, as we talked about earlier, we don’t actually know the right penetration, but we know it’s above 4% and we know it’s probably less than 15%. So I would really like to see the number, the percentage of patients seen by palliative care teams increasing and then leveling off. Those are the big trends that I think we will be seeing when we’re talking again in about six years.

Eric: So I’m just completely impressed with how our satellite campus in New York, otherwise known as Mount Sinai-

Sean: Yeah, yeah, yeah.

Eric: (laughs) Is a really, you know, putting this together and really the great work that you’re doing. I really encourage all of our listeners to take a look at this report. There’s a lot of detail in there, including for me, one of my favorite graphs was that actually what the team staffing looks like, this core interdisciplinary palliative care team staffing, based on bed size from 2009 to 2015, so less than 150 beds, 150 to 499 beds, and greater than 500 beds. And you can kinda see how you compare, your program compares to these other programs based on your hospital size. Again, really useful information. I think we can talk a lot about, “Wouldn’t it be great to have this, you know, full interprofessional staffing,” but what this graph reminds me of, is that even a full staff, like some of these are point three of a chaplain or point six of an RN on a team. And what is the right make up for different size hospitals.

Sean: I think that’s absolutely critical, Eric, and as I think that you point out at the very beginning of this podcast, one of the things about this report is it gives all of us in the field a pat on the back to show us how far we’ve come, but it really lays out where we need to go in the future because we are clearly not there yet.

Alex: Great, so I got one last question. How many programs are in this registry and if people want to be included what can they do?

Sean: That’s a very good question. We have somewhere between 3 and 400 depending upon what year you’re looking at. And if you would like to be included in the registry you can go to www.registry.capc.org and you will come up to the front page where you can register your program and input your data.

Alex: Terrific. Should we end with another verse?

Sean: I would love another verse, Alex, thank you.

Alex: Feel free to join in in the singing.

Sean: I will spare your listeners.

Alex sings “When I’m 64” by The Beatles.

Produced by: Sean Lang-Brown