NEW SERIES: Ahead of the 15th World Congress of the European Association for Palliative Care, we shall be publishing posts from our plenary speakers . . .
Today, Dr Diane Meier, Director of the Center to Advance Palliative Care, New York, USA, gives a glimpse of the plenary lecture that she will give at the congress in Madrid on Thursday 18 May 2017.
Unlike most of the rest of the world, the US has no ministry of health and no national health service to serve as a centralised governing body and standard-setter. Health care is paid for by a confusing and overlapping array of government insurance (Medicare for people over age 65 and some with disabilities), Medicaid (tied to means-testing and intended for the poor), commercial insurance (tied to employment), and individually purchased insurance. Thanks to the 2009 Affordable Care Act (ACA), the US now has the lowest rate of uninsured (11%) in our history, though following the 2016 presidential election, the stability of this accomplishment is no longer clear.
Given this complexity, the work of scaling up access to palliative care for all seriously ill people who could benefit from it requires attention to multiple levers: payment policies, regulatory and accreditation requirements and oversight, clinician training, public awareness campaigns, delivery model development and testing, and investment in research to inform the evidence base. The shift from paying for volume (so-called fee-for-service payments) to paying for value (the ratio of quality over cost) accelerated by the ACA, has heightened recent attention to, and investment in, palliative care services; not only in hospitals, but also in community settings such as nursing care facilities, the home, office and clinic practices, cancer centres, and dialysis units.
The growing payment requirement for clinicians and healthcare organisations to improve value by strengthening the quality of care, and in so doing reduce preventable crisis hospitalisations and emergency department visits, is the single largest force driving rapid growth in palliative care in the United States.
Attention to the characteristics of effective palliative care service models demonstrably linked to better quality and lower cost are essential to sustainable program design. The predictors of reliably high-value palliative care services include:
- Screening and targeting of specialist-level palliative care services to the highest need subset of the patient population;
- Comprehensive assessment, risk stratification, and matching of services to need over time;
- Interdisciplinary teams not only skilled and knowledgeable in management of complex medical illness, but also in pain and symptom management, common co-occurring psychiatric disorders, and in expert communication about patient and family priorities and how best to honour them;
- Recognition of the central role of family carers in patient-being and outcomes, requiring assessment of family needs, capacity, and willingness to serve in the carer role.
- Reliable 24/7 access to competent help, since symptom and other crises rarely occur during working hours;
- Attention to both the social and the medical determinants of poor health, such as safe housing, trauma and violence, food security, transportation, literacy, and poverty/financial challenges; and
- Transparency and accountability for measurable outcomes including patient and family experience and health care utilization.
A central development in U.S. palliative care is the recognition that most people (and their families) with serious illness and palliative care needs are not dying, but living, often for years, with highly burdensome and chronic consequences. Moving towards need (and away from prognosis) as the key indicator of eligibility for palliative care services, with a focus on improving quality of life at the same time as all other beneficial treatments, represents a fundamental shift in self-concept for the field – a return to the originating impulses of the healing professions as the foundation for all that we do.
Look out for more posts from plenary speakers on the EAPC Blog in the coming weeks.
Dr Meier will give the first plenary lecture on Progressing palliative care: Current perspectives and future directions at 10h00 to 10h30 on Thursday 18 May 2017. (Simultaneous translation into Spanish will be provided for all plenary sessions). To view the full congress programme and to register, please visit the congress website.