Allison Silvers

On June 17, 2022, Senators Rosen (D-NV), Barrasso (R-WY) and Fischer (R-NE) sent a letter to the Center for Medicare & Medicaid Innovation (CMMI) asking it to support access to palliative care wherever the patient is located —“be it at home, at a caregiver’s home, in the hospital, in a nursing or assisted living facility, or through telemedicine.” 

Palliative care treats the symptoms and stress of serious illness, and it is based on need, not prognosis. These senators recognize the tremendous benefits that it delivers, not only to patients and families but also to providers, citing improvements in both quality of life and efficient use of healthcare resources. 

The senators’ request is timely. In the last two years of the COVID-19 pandemic, demand for such services has risen, with 64% of care teams surveyed reporting an increase in the number of consultations requested, and 34% reporting a reach into new settings through telehealth, including 8% now serving long-term care settings. 

Yet despite some promising growth in relationships between palliative care and long-term care, palliative services in both skilled nursing facilities and assisted living residences remains woefully under-utilized. For example, samples from medical records reveal that 69% of nursing home patients and residents are in need of palliative care, and yet one recent study found that only 4% had received a related consult prior to death.

While a CMMI payment model, such as the one the Senators are requesting, can strengthen the ability of care teams to serve patients and residents in long-term care settings, there are already terrific opportunities available. For example:

  • Formal collaboration with palliative care teams. Specialist teams can bill Medicare Part B and Medicare Advantage plans for professional services. This does not conflict with any existing Part A or B billing, and in fact, often adds valuable documentation to strengthen the facility’s Part A billing along with other medical teams’ billing. Some facilities have also reported that palliative consultation documentation helps with quality monitoring and state inspections.

Facilities can support palliative care consultation by:

  • Building simple “triggers” into the medical record that flag patients in need of palliative care consultation. These can be based on documented pain or symptoms, or built from risk tools such as the Charlson Comorbidity Index or the LACE Tool.
  • Developing a formal partnership with a palliative care program so that a blanket order and a simple communication process (such as a one-page fax request) can be established. More recently, these partnerships have included tele-palliative care consultations, which can help expedite communications and decision-making across multiple family members and caregivers.   

Facilities that follow these practices have reported strengthened hospital referral relationships through dramatic reductions in avoidable readmissions and improved Star ratings.

  • Palliative Care Nurse Practitioners from Institutional Special Needs Plans (ISNPs). Many facilities have existing relationships with ISNPs, providing on-site nurse practitioners to enhance their clinical resources and responsiveness. These nurse practitioners can be trained in essential communication and symptom management skills, integrating palliative care into their existing responsibilities. In fact, the early Evercare model relied on palliative care approaches to reduce hospital transfers and length-of-stay, while strengthening member and family satisfaction. 

With heightened scrutiny on long-term care and an ever-expanding reliance on value-based payment, long-term care providers are beginning to embrace greater integration of palliative care into their operations. While the federal government continues to explore new Medicare payment models, forward-looking facilities can build their palliative care collaborations and capabilities right now.

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Allison Silvers is the chief health care transformation officer at the Center to Advance Palliative Care (CAPC). She launched CAPC’s payment accelerator to support programs as they pursue value-based payment. She also co-led the national Serious Illness Quality Hub, and works with national health plan leadership to define and disseminate best practices in palliative care access and payment. 

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.