Building a Sustainable Palliative Care Program 
(Part 2)

Amanda Copeland (0:00 - 1:29)
You can get so caught up in trying to do too many things that just prevent you from really staying focused on your palliative care role. I think the big part of that is just developing those relationships with other providers in the community, other providers that are a part of the team taking care of your patient and having good communication and coordination of care with them to allow each of those to perform their role, whether it's primary care or home health or the specialty providers. 

Welcome to Transcending Home Care. Stan Massey of Transcend Strategy Group holds vital discussions with other experts on insights and ideas to help providers succeed in the ever-changing landscape of home care and senior care. For more than 20 years now, Stan has helped providers build their brands to increase referrals, admissions, staff retention and performance scores. This episode is part two of a conversation with Mark Hendrix, president of nTakt, a company that specializes in building sustainable palliative care programs. Also participating is Amanda Copeland, a nurse practitioner with deep experience in providing hands-on palliative care in the field. Amanda, Mark and Stan talk about smart models of home-based palliative care, including staffing practices that maximize efficiency and effectiveness.

Stan Massey (1:31 - 1:53)
Hello, listeners. Before we dive in, I want to remind you that this is the second episode in a two-part series. You can find the first episode on Transcend's website, that's transcend-strategy.com, or wherever you downloaded this episode of our podcast. Having said that, welcome back, Mark. I'm really looking forward to picking up our conversation on building a viable palliative care program.

Mark Hendrix (1:54 - 2:00)
Thank you, Stan. It's a pleasure to talk with you again. I look forward to learning more.

Stan Massey (2:01 - 2:09)
Thank you, and welcome to you, Amanda. Thanks so much for joining us to share your experiences and insights on practicing palliative care in the field.

Amanda Copeland (2:09 - 2:12)
Hi, Stan. I'm excited to be talking with you guys.

Stan Massey (2:13 - 2:35)
Very good. Let's dive right in. Mark, in our first conversation, we talked a bit about how to structure and staff a palliative care program as a startup that you can build on. Let's dig into that topic a little bit more. Again, remind us what you see as a workable model to begin palliative care, including the staff and support an agency needs to get off the ground.

Mark Hendrix (2:36 - 3:39)
Yeah, I think really building it from the start is really the critical thing. I like to use a model that I call a nurse practitioner-driven model. It's basically a nurse practitioner that is really caring for the patient, visiting the patient. The nurse practitioner really drives everything about that patient's care. So they visit the patient. They can bill for those visits. But in the process of their exam of the patient, they will come up with a care plan, they’ll develop a care plan for the rest of the team. So that includes basically identifying the number of times they need to visit, the number of times a nurse or social worker needs to follow up with them between visits, their medications and their medication requirements, and many other things that Amanda can probably explain much better than I. I also just emphasize that social workers can also be used in that model. And I hope we get to discuss that some more in today's call.

Stan Massey (3:40 - 3:53)
Very good, Mark. That's a perfect segue for my first question for Amanda. Amanda, what does that model translate into for the nurse practitioner's workday? How do you schedule and manage an NP's caseload?

Amanda Copeland (3:54 - 5:55)
That's a great question. The first thing is just knowing that you've got to be very flexible, knowing that each day may bring scheduling challenges as you come across patient needs. The goal of scheduling the day is to make sure that you've got enough time allotted for spending with the patient to provide them with plenty of time to discuss all of their questions and needs. Typically, that looks like a two-hour visit for a new patient and at least an hour for a follow-up patient. The other part of structuring that day has to include drive time. That may vary dependent on where you live, the area that you're covering. That just has to be factored into that day to ensure that you're going to have that drive time available to you between patients. Usually, a typical day will look like scheduling what we call four equivalent visits. What that translates into is each new patient visit is considered two equivalent visits and each follow-up is considered one.

There are a variety of ways to schedule. What we have found to be best is to have some flexibility in that schedule for the week to be able to work in new patients. Leaving some room for that and then scheduling each follow-up visit with the patient as you're with them so they know when they're coming back. They've got it on their calendar. They've already got that appointment scheduled and that allows them to know when you're coming back. Also, they know that they can reach out to you if they need something sooner.

Stan Massey (5:56 - 6:26)
That's great. That was a very thorough explanation. I really appreciate that. I have a related question to that, Amanda. Based on what you just described, the frequency of palliative care visits can vary significantly based on the patient's conditions but in general, how many different patients does that model that you just described typically allow a nurse practitioner to care for? I know there's all those factors that you just named, but what is the target caseload per NP that you use as a guideline?

Amanda Copeland (6:27 - 6:53)
We had to adjust that number as we grew and developed our program. What we found to work really well is a target caseload of 70 patients. That allows you to be able to do a typical day as we described previously. It allows you to make room for new patients and allows you to be able to have the time that you need.

Mark Hendrix (6:53 - 7:42)
One thing I'd like to add to what Amanda is saying is that the caseload is also dependent upon the type of support staff that the nurse practitioner has. What I see nationally is that many nurse practitioners don't have the support staff for follow-ups and follow-up phone calls as other staffs. Amanda may be able to address that as well as so far as what support staff she has, but the ones that don't have as strong a support staff cannot care for as many patients in their caseload. I also feel like the ones that don't have that support staff have more difficulty transitioning patients to hospice and keeping the patients out of the hospital.

Amanda Copeland (7:43 - 8:23)
I totally agree, Mark, because having the support staff that you need to be monitoring your patients in between your visits is key. If you don't have that, then that's follow-up that the nurse practitioner needs to be doing to accomplish exactly what you said of trying to make timely and appropriate transitions to hospice as well as trying to keep them from having to go back and forth to the hospital. If you don't have someone helping you with the monitoring in between your visits, then you may need to visit more frequently, but you may also have to allot more time to be able to do follow-up phone calls.

Stan Massey (8:24 - 8:43)
Very good information. Thank you both for that. Amanda, speaking of other support roles, what are some of those other roles you see necessary in a startup model? Mark mentioned earlier social workers. What skill sets do you recommend for filling the roles that you see in a startup?

Amanda Copeland (8:44 - 11:05)
Ideally, Stan, you would have a nurse that is able to help with just the clinical aspect of patient care and helping to do that monitoring process with the clinical viewpoint. That's invaluable. They're able to provide a lot of education and support to patients, even if it's just by phone. If there's not the ability in the start to allow for nurse home visits, even by phone, they can provide so much support. They can help really build and develop the relationship between the palliative care team and the family and patient. A nurse is an invaluable part of the team. 

Social workers can bring so much. We don't have one, but I see so much benefit in having them because they can also provide a lot of education and support. There are so many needs that patients and families have when they're dealing with these serious advanced illnesses, whether it be just identifying those community resources or providing that emotional support that they're in need of and just providing a listening ear and communicating concerns and changes with the rest of the team to help with just that care plan and help with adjusting follow-up visits if necessary to get patients seen sooner. Those two roles are very, very helpful in providing the support to the nurse practitioner as well as the necessary support to the patients and families.

The scheduling part can be very challenging. Having someone that's designated for scheduling, that role could potentially be managed by different parts of the team or you could have someone that is specifically designated to help with that because that can be, like I said earlier, you have to be very flexible in scheduling and there's a lot of changes that occur every day in that. So, having someone as a part of the team to do that can be a huge help to take a load off the nurse practitioner.

Stan Massey (11:06 - 11:29)
Very good. Mark, we talked in the first episode about certain tasks in palliative care being covered by Medicare Part B if agencies are using the correct CPT codes. Does the kind and level of activity Amanda is talking about allow for enough reimbursement to cover the salary of a nurse practitioner or these other roles or is that a loaded question?

Mark Hendrix (11:32 - 13:41)
It's definitely somewhat loaded. With the caseload that Amanda has, she can more than cover her salary with using the right CPT codes and especially if you use the advanced care planning codes. A little bit more of a challenge in 2023 with the new codes and some of the non-face-to-face billing codes have been eliminated but G codes have been added to replace those and those G codes, if used properly, can make up for some of the non-face-to- face. Plus, in the current 2023, there's actually an 11-day window of time that you can bill for some other services that were not allowed for in 2022. So, we're in the middle of a learning curve right now in 2023 about new billing codes, but the opportunity is there. I see it every day. That said, as a stand-alone entity, palliative care is still not something to where people are going to go out and just start just palliative care programs. It still shines in an environment where it provides a continuum of care between home health and hospice and palliative care. It fills that gap that's really vacant in our healthcare system today. So, it's still viable. 

One of the things that part of that making it viable, you and I have talked about it Stan before, is keeping it very simple. I see a lot of programs that really get too much into primary care or too much into other fields, too much in the home health, too much in the hospice, and they try to define themselves in too much in those areas such as DME, wound care, some of those type things. I'd be interested in knowing what Amanda said about keeping it simple and not really getting too much into the weeds of those things and coordinating that care. But in my view, that's another critical component of financial viability.

Stan Massey (13:41 - 13:43)
Great. What are your views on that Amanda?

Amanda Copeland (13:44 - 14:58)
I totally agree with Mark's thoughts on keeping it simple because you can get so caught up in trying to do too many things that just prevent you from really staying focused on your palliative care role. I think the big part of that is just developing those relationships with other providers in the community, other providers that are a part of the team taking care of your patient and having good communication and coordination of care with them to allow each of those to perform their role whether it's primary care or home health or the specialty providers. Just working with them to make sure that the needs are met for the patients but not necessarily trying to take on all of that yourself because you really can get overwhelmed and then you're losing focus of what you're there for, which is palliative care, which is providing that focus on symptom management, improving quality of life, identifying goals of care, and having those serious healthcare discussions. And if you're too caught up in the other things, then I think you can lose sight of those things that you really need to be focusing on.

Stan Massey (14:58 - 15:26)
That's really good advice. I also wanted to ask you Amanda, you mentioned in some of your earlier comments about scheduling the nurse practitioner’s day and other people on the team and you had mentioned windshield time. What do you do to more efficiently plan a nurse practitioner's day or route and what do you see as the role of telehealth playing in the future on helping to increase that efficiency?

Amanda Copeland (15:27 - 16:20)
That's a great question. You know the travel time is definitely a challenge at times and it depends on your territory and you know everybody's got to figure that out for themselves. But as you know your area, as you know your patients, you really can utilize the opportunity of scheduling follow-ups yourself for your patients to make sure that you are grouping patients in similar areas so that you don't have so much drive time between patients.

So just grouping them whether it's you've got, like myself, I have a large county that I cover and so there may be smaller areas throughout the county that I have a majority of my patients in and so I just group my day in those areas so that I'm not driving so much in between.

Stan Massey (16:20 - 16:26)
That makes sense. Are you currently using telehealth a lot or what do you see the role for that as we go forward?

Amanda Copeland (16:27 - 17:50)
Well not currently using it a lot but with telehealth, I think especially in these rural areas, especially in these large territories that people may be covering, it opens up so much opportunity just to monitor patients a little more closely. You know allows you the opportunity to see more patients in a day. It helps to simplify things for patients as far as doing that telehealth visit.

If the technology works for them, that's not something that every patient loves, but just in being able to offer them more options of visits whether, you know, most patients love home visits that's not typically a problem, but sometimes a telehealth visit is just better for patients. They appreciate that option of care. So I think the main things though are just being able to cover a large territory, a larger number of patients but still providing the appropriate follow-up visits and being able to see patients in a timely manner and if you have a patient that has an acute need that arises but yet you're not available to make a visit that day, but you can do a telehealth visit so it allows you to see them that same day when maybe you wouldn't have been able to otherwise.

Stan Massey (17:51 - 18:13)
That makes a whole lot of sense. Mark, we've been talking both episodes about building a palliative care program. We've gone over some of the structure for a good startup, but what are the indicators that it's time to add staff or otherwise expand a palliative care program? Is it strictly caseload or what are the other factors?

Mark Hendrix (18:14 - 19:40)
Well certainly caseload is one of the factors, but I do recommend that when you start building a program that you build it tall and then wide. In other words, within an area if you're expanding into multiple areas get one area the process is down and everything working really well in that one area before you branch out and make it wider. And this is probably one of the key things that I see mistakes that people have is they try to start a program and they put a lot of nurse practitioners all over a state in some cases and none of those individual areas are efficient yet and so problems are just multiplied that way. So, start with a pilot program, start with a pilot area, get the processes down, get the billing down, fine-tune it and then grow wider, then expand. But to me it's more than just caseload. An opportunity to me everything comes back to effective training and it doesn't matter how great the technology is, you've got to have hands-on training and you've got to have good processes in place in order to make all the technology and all the people pull together into a program that really works and really takes great care of patients.

Stan Massey (19:41 - 19:48)
Very good. Amanda are there any other factors that Mark didn't mention that you would consider when it's time to add to your staff?

Amanda Copeland (19:49 - 20:37)
Well, I think just as he said but also that caseload is an important part of that. As you start seeing that you are increasing in your caseload, that you're finding it to be more challenging with making sure that you have appropriate follow-up with patients, you have room for new referrals. And if you find that that's becoming more and more difficult, then I think you've got to reevaluate. What's the plan moving forward, because it's all about providing excellent care to patients and families. And you know the staff is overwhelmed and not able to monitor appropriately, not able to visit in a timely manner, then I think you really lose a lot of opportunity to provide that care that they need.

Stan Massey (20:39 - 20:49)
Thank you for that. My last question and this is for both of you, what haven't we talked about yet that you think is important to discuss regarding a viable palliative care model?

Mark Hendrix (20:50 - 21:47)
We haven't talked a lot about training in my opinion. I think training is important and it's important to have consistent training. I'll use billing as an example. There are some new billing changes in 2023 that we just mentioned and there's a lot of information out there about how to use those codes and how to apply them. And so there are many, many, many different ways to get that training. I like to recommend from a training standpoint that you identify a source and let that be your trusted source for training on billing and really for training on anything. And instead of trying to go across the country and get a lot of different ideas about how to bill, have a trusted source that you can rely on and always rely on them and trust them. But I think training is a huge part of it. We could probably talk an hour about training.

Stan Massey (21:48 - 21:53)
Well, maybe that's another podcast episode, Mark. Amanda, any final thoughts from you today?

Amanda Copeland (21:54 - 22:42)
Yes, the training is so important because as providers, as healthcare professionals, we all want to have the knowledge that we need to provide the care that patients need, so that training for us is so important. But also just making sure that we're developing those relationships within your healthcare system, within your healthcare community to make sure that everybody is aware of your program. They understand what your services are all about, so that they're able to refer appropriate patients, so that they're able to communicate and have that coordination of care that patients need. And so just good relationships throughout the community, throughout the healthcare organization.

Stan Massey (22:43 - 23:04)
Well, that seems like a very good thought to end our episode on today. So, Mark and Amanda, thank you both so much for sharing your insights and advice on growing a sustainable palliative care program. And I wish you all the best as you both keep working to gain traction for all the tremendous value that palliative services can bring to the continuum of care. Thanks so much for being our guests today.

Mark Hendrix (23:04 – 23:05)
Thank you, Stan.

Amanda Copeland (23:05 – 23:06)
Thank you so much, Stan. 

Thanks for listening. Watch for future episodes of Transcending Home Care on iTunes, Spotify, Stitcher and iHeart Radio. For more content, visit transcend-strategy.com.