Breaking Down Barriers to Earlier Referrals

Providers of home health services, palliative care and hospice care often express disappointment and confusion regarding referral patterns by physicians. Many providers feel physicians don’t refer to them as early as they should or may be missing the full benefits they can provide to patients and families alike.

“Late” referrals to hospice and palliative care are confirmed by Medicare data and surveys with physicians. The most current Medicare data show that 40.5 percent of hospice patients receive hospice care for 14 days or less. Nearly 54 percent are on a hospice program for 30 days or less. And that’s out of an available 180 days of coverage – or possibly more if a patient re-evaluation still deems hospice care as appropriate.

Regarding palliative care, many physicians admittedly don’t distinguish it in their minds from hospice care. In surveys and focus groups conducted by Center to Advance Palliative Care, the vast majority of physicians said they consider palliative care as comfort care for the very end of life – not reflecting the full support it provides at any stage of any serious illness.

 

Obstacles to knowing when supportive care is the right call

The mindset that blends hospice and palliative care as being for the last days of life is compounded by the challenge of accurately estimating a patient’s remaining life span. In a well-known study by Harvard physician and researcher Nicholas Christakis, 63 percent of physicians overestimated their patients’ life expectancy. The average amount of time for the overestimation was 525 percent!

This information is not intended to disparage any physician’s ability to correctly predict how long a patient will live. With ongoing advancements in medical science and the unpredictability of prominent diseases such as dementia, accurate estimates of life expectancy can be a moving target and a real mystery.

In addition, physicians are trained to cure and can be reluctant to “give up” on a patient by saying it’s time for hospice care. Even when physicians know the odds of a treatment being successful are diminishing, many will continue treatments if the patient – or their family – insist on “doing everything possible.”

Physicians are usually transparent about the chances of success and may even talk about the affect on quality of life if a treatment has harsh effects. However, Atul Gawande, MD – author of The New York Times bestseller Being Mortal – wrote, “We are increasingly the generals who march the soldiers onward, saying all the while, ‘You let me know when you want to stop.’ All-out treatment, we tell the terminally ill, is a train you can get off at any time – just say when. But for most patients and their families, this is asking too much. They remain riven by doubt and fear and desperation; some are deluded by what medical science can achieve. They need doctors and nurses who are willing to have the hard discussions and say what they have seen, who will help people prepare for what is to come – and to escape a warehoused oblivion that few really want.”

3 keys to opening doors for earlier referrals

Now that we’ve thought about some of the major obstacles to referrals from physicians, consider these recommendations to start changing physicians’ understanding of how you can help:

1. Position palliative care as a partner with curative treatment. Since many physicians focus on continuing curative treatments throughout a serious illness, position your palliative care program as an ideal complement … not a last resort for comfort during life’s final days. Educate physicians and their office teams about palliative care’s efficacy in managing pain and other symptoms, as well as the side effects of curative treatments – appropriate for any stage of serious illness. Make it clear that the physician is still in charge of the patient’s care plan and that your palliative program will coordinate with that plan as the physician dictates.
2. Redefine the timeframe of hospice away from just the final days or weeks. This recommendation is easier said than done. But the more you can educate about the full support of hospice care for six months or even longer, the better the odds of changing physicians’ mindset about when hospice care is appropriate. One client of Transcend Strategy Group has started using a timeline graphic that shows the full duration of hospice care, with the last sliver identified specifically as “end-of-life care.” It’s a strong visual representation that the way many people view hospice care is only a small part of the bigger benefit.
3. Make sure to discuss all comorbidities with physicians for comprehensive home health referrals. This article hasn’t delved into home health per se, but home health providers confront obstacles of their own in getting the most comprehensive referrals from physicians. The ever-important face-to-face documentation with physicians for home health referrals offer the greatest opportunities to provide the right care for the most appropriate periods of time. Is your staff highly trained to explore all relevant comorbidities for each patient in addition to getting the primary diagnosis correct? The more you know about the full gamut of primary and secondary diagnoses, the greater your opportunity for more comprehensive referrals and the most effective care for patients – and it’s an increasingly crucial factor of your reimbursement in the new PDGM era.

Want to hear more about overcoming barriers to physician referrals – with valuable insights directly from a physician? Listen to our interview featuring Michael Paletta, MD, FAAHPM, chief medical officer for Hospice of Michigan embedded at the beginning of this post or on Apple Podcasts.