Reimagining the Inpatient Palliative Care Consult: Lessons From COVID-19

ABSTRACT

As the number of inpatients with advanced age and chronic conditions rises, so too does the need for inpatient palliative care (PC). Despite the strong evidence base for PC, less than 50% of all inpatient PC needs are met by inpatient consults. Over the past several months in epicenters of the COVID-19 pandemic, PC providers have responded to the increased need for PC services through innovative digital programs including telepalliative care programs. In this article, we explore how PC innovations during COVID-19 could transform the PC consult to address workforce shortages and expand access to PC services during and beyond the pandemic. We propose a 3-pronged strategy of bolstering inpatient telepalliative care services, expanding electronic consults, and increasing training and educational tools for providers to help meet the increased need for PC services in the future.

Am J Manag Care. 2021;27(7):e215-e217. https://doi.org/10.37765/ajmc.2021.88704

Takeaway Points

• The COVID-19 pandemic led to rapid experimentation with and development of new models of palliative care (PC) delivery.
• Digital models should be formalized and implemented at scale by bolstering inpatient telepalliative care services, expanding electronic consults, and increasing training and educational tools for non-PC providers.
• Ongoing investment in digital infrastructure, accessible technological tools, and payment mechanisms will be needed to ensure sustainability.

As the number of inpatients with advanced age and chronic conditions rises, so too does the need for inpatient palliative care (PC). Through symptom management, patient and family support, and conversations about goals of care, PC improves quality of life and decreases rehospitalizations.^1-3 Despite the strong evidence base for PC, less than 50% of all inpatient PC needs are met by inpatient consults.^4,5

Without ready access to more PC providers, our health care system must respond to the growing need with innovative technologies and creative workforce solutions. Over the past year in epicenters of the COVID-19 pandemic, health systems have rapidly developed and scaled telemedicine PC services to address a workforce shortage that is more pressing than ever before.⁶ New delivery models have brought ambulatory telepalliative care programs into the inpatient setting and turned pilots into enterprise services, enabling patients to access care in new ways.⁷

In this article, we explore how digital innovations in PC during COVID-19 have changed how hospitalized patients receive PC and propose how COVID-19–era models could be adapted to address the PC shortage beyond the pandemic (Table).

Bolstering Inpatient Telepalliative Care

During COVID-19, health systems have established successful inpatient telepalliative care programs to assist with urgent conversations about goals of care and to provide symptom management recommendations in overcrowded emergency departments and intensive care units.^8-11 Moving forward, hospitals should formalize and expand these telepalliative care programs to meet the needs of more patients. Institutionalized telepalliative care programs could engage an array of providers—ranging from inpatient PC specialists to patients’ outpatient PC providers, oncologists, and primary care providers—to address advance care planning and subacute inpatient issues. Many outpatient providers, especially oncologists and primary care providers, already join family meetings with inpatient teams and support care delivery for hospitalized patients on top of full-time outpatient clinical duties.¹²

The unpredictable course of events for hospitalized patients increases the complexity of reliably scheduling televisits. The success of inpatient telepalliative care will therefore require new mechanisms to schedule visits. Health systems could develop a basic inpatient calendar, which would allow televisits with outpatient providers to be scheduled alongside tests and procedures. Ambulatory PC providers will also need to build time into their schedule templates to include visit slots for inpatients.

For small or rural hospitals, telehealth and PC phone hotlines can help clinical teams access a centralized PC consult service for recommendations and guidance. During COVID-19, some states developed phone hotlines to address PC questions in real time, and professional organizations like the Center to Advance Palliative Care held virtual office hours for providers around the country.^6,13 Real-time access to more localized hotlines for questions or office hours could further improve timely access to services.

Telepalliative care programs require improvements in video visit hardware and software to allow patients who are less technically savvy to use these tools in any setting. Video visits must be made accessible with as few clicks as possible, and devices should use large buttons, intuitive interfaces, and built-in speakers that make them simple and effective. Other features, such as the ability for providers to send an invite to the patient and to request to turn on patients’ audio and video, may simplify the experience further.¹⁴

Expanding Electronic Consults

Although many inpatient PC consultations require in-person history and physical examination, remote electronic consultation with chart evaluation (e-consults) may be sufficient to provide guidance on focused questions (eg, symptom management). During the pandemic, PC programs have employed e-consults for rapid recommendations, developing scripts for commonly encountered scenarios, and standardized electronic templates to facilitate documentation.¹⁵ e-Consults can serve as a tool for non-PC providers to receive timely guidance on a large number of patients without overwhelming PC providers.

Prospective triggers, or targeted automatic e-consults, are another tool for connecting patients to the right level of consultative PC. Bypassing the requirement for primary teams to request consults may facilitate timely care.¹⁶ Prior to the COVID-19 pandemic, barriers to widespread implementation of e-consults included the need for institutional investment, leadership, and clinician incentives. Since the pandemic, many institutions have overcome these barriers, using clinical triggers, chart review, and brief provider interviews to proactively connect patients to specialty PC consultation and support providers through e-consults.⁹ These clinical triggers could be further developed and built into the electronic health record (EHR) system. For example, a predictive screening tool used to identify patients with a high likelihood of 1-year mortality could be one means of identifying patients appropriate for consultation.¹⁷ Clinical triggers that prepopulate an electronic order for PC e-consults can minimize the fatigue associated with EHR alerts and pop-ups.

Although some patients may require the entire interdisciplinary team to be present for an effective consult, others may only need focused intervention from a single discipline. For example, a patient with complicated psychosocial support needs only may be best served by a PC social worker alone. Patients who need advance care planning alone could receive support from clinicians or PC interdisciplinary providers. Choosing from a tiered menu of different consult types and consulting team members to fit a patient’s clinical need can optimize the unique and diverse skill sets of interdisciplinary PC teams. Electronic decision support tools within a curated order set may facilitate selection of the optimal consult type.

Increasing Training and Educational Tools

The limited supply and bandwidth of PC specialists, combined with the often unpredictable clinical course for hospitalized patients, requires non-PC providers to make appropriate symptom management, end-of-life care, and complex referral decisions independently. Despite the ubiquity of PC needs, many providers receive limited training on symptom management principles and communication around end-of-life care. Digital tools can bridge this skills gap. VitalTalk and the Center to Advance Palliative Care, among other organizations, have released free materials to train clinicians in communication skills, particularly around COVID-19.¹⁸ Although large multiday trainings may not be feasible for providers during a pandemic, institutions can collate high-yield materials, make them easily accessible, and design brief virtual trainings for providers.

In the future, embedding order sets and decision-making support into EHRs could augment providers’ ability to deliver PC without the need for PC consultation. Prognostication and mortality estimation calculators may facilitate advance care planning documentation. For symptom management, opioid equivalence calculators and curated order sets that highlight first- and second-line medications may help hospitalists independently manage symptoms including pain and dyspnea.

Ensuring Sustainability

Sustainably building on the innovations of the past several months in PC will demand 4 key factors. First, new digital tools, including telehealth videoconferencing platforms, must achieve a balance across security (eg, personal health information protection), usability (eg, accessible hardware and software), and performance (eg, video and audio quality, connectivity). EHRs that integrate with digital tools seamlessly can improve the user experience for patients and providers alike. Embedded video platforms should facilitate sharing laboratory tests, images, and educational materials with patients. For example, patients and providers could work together on goals-of-care worksheets in real time on an “e-whiteboard” stored within the EHR.

Second, patient-facing video platforms must adapt to ensure usability and access across patient populations to overcome the “digital divide,” which disproportionately affects patients of advanced age and lower socioeconomic status.¹⁹ Platforms that function on the web and on different operating systems (eg, Android, iOS) may allow a broader range of patients to access services. Organizations should also invest in robust technology support teams who help patients access and troubleshoot digital tools.

Third, reimbursement policies for virtual care, including payment parity for video visits and reimbursement for inpatient e-consults, must be expanded to support the ongoing use of and investment in these technologies.

Finally, the long-term success of digital innovations requires patient and provider engagement and satisfaction. Research to better understand patient and provider perspectives that parallels implementation efforts will enable systems to incorporate real-time feedback into process and product improvements.

Conclusions

The COVID-19 pandemic accelerated health care systems’ transition into the era of telemedicine, transforming nearly every clinical service in a matter of months. PC in particular has adapted to the unique demands of the COVID-19 pandemic through a variety of digital health tools and workflows, including telehealth, e-consults, and training tools. If further supported and scaled, digital innovations can facilitate a care model that allows PC and providers to work together to provide essential PC to more patients and to overcome the constraints of a relatively fixed specialty workforce—during the pandemic and beyond.

Author Affiliations: Department of Medicine (SG, TJ) and Division of Palliative Medicine (JH), University of California, San Francisco, San Francisco, CA.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (SG, JH, TJ); analysis and interpretation of data (JH); drafting of the manuscript (SG, JH, TJ); critical revision of the manuscript for important intellectual content (JH, TJ); administrative, technical, or logistic support (SG, TJ); and supervision (SG).

Address Correspondence to: Smitha Ganeshan, MD, MBA, Department of Medicine, University of California, San Francisco, 505 Parnassus Ave, San Francisco, CA 94143. Email: smitha.ganeshan@ucsf.edu.

REFERENCES

1. Institute of Medicine. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. The National Academies Press; 2013. doi:10.17226/18359

2. Zimmermann C, Riechelmann R, Krzyzanowska M, Rodin G, Tannock I. Effectiveness of specialized palliative care: a systematic review. JAMA. 2008;299(14):1698-1709. doi:10.1001/jama.299.14.1698

3. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non–small-cell lung cancer. N Engl J Med. 2010;363(8):733-742. doi:10.1056/nejmoa1000678

4. Dumanovsky T, Augustin R, Rogers M, Lettang K, Meier DE, Morrison RS. The growth of palliative care in U.S. hospitals: a status report. J Palliat Med. 2016;19(1):8-15. doi:10.1089/jpm.2015.0351

5. Kamal AH, Bull JH, Swetz KM, Wolf SP, Shanafelt TD, Myers ER. Future of the palliative care workforce: preview to an impending crisis. Am J Med. 2017;130(2):113-114. doi:10.1016/j.amjmed.2016.08.046

6. Abbott J, Johnson D, Wynia M. Ensuring adequate palliative and hospice care during COVID-19 surges. JAMA. 2020;324(14):1393-1394. doi:10.1001/jama.2020.16843

7. Finucane AM, O’Donnell H, Lugton J, Swenson C, Pagliari C. Digital health interventions in palliative care: a systematic meta-review and evidence synthesis. medRxiv. Preprint posted online September 18, 2020. doi:10.1101/2020.09.16.20195834

8. Calton B, Abedini N, Fratkin M. Telemedicine in the time of coronavirus. J Pain Symptom Manage. 2020;60(1):e12-e14. doi:10.1016/j.jpainsymman.2020.03.019

9. Schoenherr LA, Cook A, Peck S, et al. Proactive identification of palliative care needs among patients with COVID-19 in the ICU. J Pain Symptom Manage. 2020;60(3):e17-e21. doi:10.1016/j.jpainsymman.2020.06.008

10. Lee J, Abrukin L, Flores S, et al. Early intervention of palliative care in the emergency department during the COVID-19 pandemic. JAMA Intern Med. 2020;180(9):1252-1254. doi:10.1001/jamainternmed.2020.2713

11. Flores S, Abrukin L, Jiang L, et al. Novel use of telepalliative care in a New York City emergency department during the COVID-19 pandemic. J Emerg Med. 2020;59(5):714-716. doi:10.1016/j.jemermed.2020.08.008

12. Gadzinski AJ, Andino JJ, Odisho AY, Watts KL, Gore JL, Ellimoottil C. Telemedicine and eConsults for hospitalized patients during COVID-19. Urology. 2020;141:12-14. doi:10.1016/j.urology.2020.04.061

13. Center to Advance Palliative Care. Accessed November 9, 2020. https://www.capc.org/

14. Perissinotto C, Zhang C, Oseau T, et al. Feasibility of a tablet designed for older adults to facilitate telemedicine visits. Innov Aging. 2019;3(suppl 1):S975. doi:10.1093/geroni/igz038.3534

15. Ankuda CK, Woodrell CD, Meier DE, Morrison RS, Chai E. A beacon for dark times: palliative care support during the coronavirus pandemic. NEJM Catalyst. Published online May 12, 2020. doi:10.1056/CAT.20.0204

16. Wachter RM, Judson TJ, Mourad M. Reimagining specialty consultation in the digital age: the potential role of targeted automatic electronic consultations. JAMA. 2019;322(5):399-400. doi:10.1001/jama.2019.6607

17. Cardona-Morrell M, Hillman K. Development of a tool for defining and identifying the dying patient in hospital: Criteria for Screening and Triaging to Appropriate aLternative care (CriSTAL). BMJ Support Palliat Care. 2015;5(1):78-90. doi:10.1136/bmjspcare-2014-000770

18. Berns S, Hurd C, Carl J, Roshal A, Lindenberger E. Practice makes permanent: VitalTalk techniques for drilling communication skills (FR482F). J Pain Symptom Manage. 2016;51(2):385. doi:10.1016/j.jpainsymman.2015.12.260

19. Scott Kruse C, Karem P, Shifflett K, Vegi L, Ravi K, Brooks M. Evaluating barriers to adopting telemedicine worldwide: a systematic review. J Telemed Telecare. 2018;24(1):4-12. doi:10.1177/1357633X16674087