Rural Palliative Care

Evidence is mounting for this community-based approach

Palliative care has been gaining momentum as a care delivery method. This approach to managing chronic disease and other serious and advanced illness—centering on relieving suffering and improving quality of life for patients and their families—has slowly proven itself as an effective means to improve quality of life, enhance care delivery, and conserve limited health care dollars.

Nationwide systematic changes in care delivery take time. Hospice was first introduced in the 1960s. Two decades passed before it became a provisional Medicare benefit, finally becoming a guaranteed benefit in 1993. Clinical and fiscal evidence is mounting in favor of broadly implementing palliative care.

A study published in 2010 by the New England Journal of Medicine showed that lung cancer patients who received palliative care early lived longer and chose less aggressive care than patients receiving standard care.1

A recent study of palliative care team consultations for Medicaid patients at four New York State hospitals, showed that, on average, patients who received palliative care incurred $6,900 less in hospital costs during a given admission than patients who received standard care. Consistent with the goals of a majority of patients and their families, palliative care recipients spent less time in intensive care, were less likely to die in intensive care units, and were more likely to receive hospice referrals than similar patients.2

"We now have the scientific evidence for what we knew in our hearts all these years," said Julie Pahlen, director of the LifeCare Home Medical Center, and participant in Stratis Health's Minnesota Rural Palliative Care Initiative.

The models for palliative care programs come from urban settings focused on hospital-based programs, with higher patient volumes that allow for offering specialized care. In resource-strapped rural communities, these models don't apply. Recognizing the need to support palliative care, Stratis Health leads learning collaboratives aimed to develop or strengthen palliative care services in rural areas. Without models for palliative care in rural communities, Stratis Health used community capacity development theory to help the communities create programs that meet their needs.

Building community capacity

Developed within the public health realm, community capacity development theory focuses on transferable knowledge, skills, systems, and resources that affect change on the community and individual levels.

Consistent with the community capacity approach, each team in Stratis Health's collaboratives identifies its current gaps in service, needs of its community, and available resources. The teams then develop a program matched to the needs and resources in their community.

Because palliative care is about caring for the whole person, it requires the support of a multidisciplinary team. The communities that have participated in the initiatives have built and strengthened relationships across departments and across organizations in order to develop and support palliative care services.

"Our palliative care efforts have strengthened our health care community. It's pulled us together and had us look at the team approach to better serve patients," said Pahlen. "We now have put faces to agencies, and we've shared concerns back and forth."

This connectivity will serve them well in supporting other cross-setting initiatives, such as health care homes and reducing hospital readmissions, which are gaining national prominence. Numerous tools exist to address barriers in care coordination and reducing hospital readmissions—the primary challenge is bringing together community teams to implement the tools, processes, and services.

"We need to find creative ways of bringing together interdisciplinary teams," said Rhonda Wiering, regional director of quality initiatives, Avera Health System, and member of Stratis Health's rural palliative care advisory committee.

Emerging models

Palliative care programs are emerging from various settings in rural communities—home health agencies and nursing homes, as well as hospitals.

"A key finding from our first collaborative was that rural communities can find a way to provide palliative care services," said Karla Weng, Stratis Health program manager. "Programs can develop wherever the skill sets and champions are found."

Stratis Health has helped foster programs that have grown from a passion of health care providers who have seen patients suffering in the care gap between treatment and hospice care. With time, these programs may serve as models for implementing palliative care in rural areas throughout the country.

"If we do not have palliative care in our rural sites, we are going to fail people," said Wiering.

1. Temel et al. Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer. New England Journal of Medicine. August 2010; 363:733-42.
2. Morrison et al. Palliative Care Consultation Teams Cut Hospital Costs For Medicaid Beneficiaries. Health Affairs, 30(3), 454-463.