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Incentivizing Palliative Care Referrals in Emergency Rooms

The Problem:
In addition to the abundant need for discussing patient end-of-life goals, emergency departments have other competing interests, including long waits, patient flow, critically ill/trauma patients and other significant capacity issues.

The Goal:
MUSC Health sought to increase early referrals to palliative care in order to establish goals of care, improve the quality of care for patients with terminal illness and improve the overall patient’s experience.

Method & Implementation:
The law of unintended consequences suggests that creating large, complex systems will eventually produce unintended outcomes. This is a particularly prominent problem in a hospital where different providers, departments, insurers and kinds of people all collide together with their own particular set of interests.

“Discussing end of life goals and expectations for the first time when a patient in an emergency department is delicate and time-consuming” points out Christine Carr, MD, past director of the emergency department at MUSC. “Recently evidence has emerged demonstrating palliative care involvement early in a terminal illness reduces anxiety and depression, and in many cases extends life. It also reduces unnecessary hospital admissions and procedures, improving the quality of the remaining time a patient has with family and friends”.

Palliative care, which is often confused with hospice care, helps patients with serious chronic illnesses think holistically about their treatment plan, comfort and quality of life instead of simply diagnosis and treatment. Patients are assisted in developing informed goals of care that they can share with family and providers (including in the ED).

“Consider something like heart failure, that’s medically managed,” Carr points out as an example. “Say you’ve had a number of heart attacks and for some reason, potentially it’s your kidney function, you are not a candidate additional stents, caths or surgeries. We just have to do the best we can and optimize medical management, knowing there is a very good chance you’re going to have another heart attack. Those patients are really good candidates for a palliative care consult. And a lot of other indications like that become apparent [over time].”

Recognizing the value of palliative care, the emergency department at MUSC decided to link a slice of physician incentive pay to palliative care referrals.

“We [pick something] every year where we use a portion of our pay to incentivize certain behaviors with what we think is important as an organization,” explains Carr. “In our case linking ED Palliative Care referrals to a financial incentive demonstrates that senior leadership believes [in it]. We all have to believe and understand the value of it for it to be successful.”

Carr says the physicians appreciated the difference these referrals made immediately.

“We are constantly thinking about patient flow in the ED, and we worry about all the other sick patients in the waiting room that we can’t see any need to get them back for an evaluation. We have to be careful to order only the tests and consults that need to occur in the ED, and let the more elective tests and consults occur once the patient is admitted (so we can get the patients waiting for care back to be seen). Initially with the new Palliative Care service at MUSC we were concerned about the delays in care getting an ED consult would cause. “We really thought initially Palliative Care in the ED more just about getting patients into hospice, which frankly we could do ourselves. So, we [collectively] didn’t fully understand the whole value of establishing goals of care and maybe sending patients home. In our case, at least, the palliative care team was set up to help us with end-of-life narcotics, oxygen at home, durable medical equipment—stuff that we never do in the ED. They ended up bringing a lot of other services that we didn’t even think about. Most importantly the patients were much more satisfied and felt in control of their care”

The result is that physicians continue to make palliative care referrals even after the financial incentives went away. The practice of requesting a palliative care consult, which was once reinforced by financial incentives, has now become embedded in the emergency department’s culture.

Carr sees the initiative as a prime example of changing how a system functions in a way that positively affects a patient’s experience and quality of life.

“Patients need palliative care. They need to establish goals of care and what do they want the rest of their life to look like. So, we make that happen [now],” she concludes. “Having a senior leadership team own it, believe in it, support it financially, really ensured our success.”