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Why Population Health and Palliative Care Need Each Other

Why Population Health and Palliative Care Need Each Other Two evolving disciplines in medicine have brought new ways of thinking about health and disease. One is palliative care, which focuses on improving the quality of life of patients with serious illnesses and their families. A second is population health, which focuses on improving the health of populations, with a special emphasis on reducing disparities in health outcomes and improving the value of health care. Although palliative care and population health are related, there has been limited discussion about how these 2 disciplines can support and complement each other. This synergy is key to improving the quality of care of frail older persons with chronic, life-limiting illnesses. In this Viewpoint, we describe the potential synergies between these 2 disciplines and propose next steps to foster collaboration. What Population Health Can Learn From Palliative Care The concept of population health is not new,1 but it has gained increasing attention in conjunction with the triple aim.2 More recently, its integration into the Affordable Care Act has increased the national prominence of population health.3 As population health develops, there are several ways that it could be strengthened by adding elements of palliative care. For instance, palliative care focuses on patient-centered outcomes such as quality of life, symptom burden, emotional and spiritual well-being, caregiver burden, and bereavement. This more inclusive approach complements the traditional emphasis of population health on reducing morbidity and avoiding mortality. Palliative care can also contribute a frank and open discussion about the value of treatment near the end of life. This is particularly relevant to population health management (also known as “population medicine”), which focuses on improving the health of clinically defined groups.4 Although the value of health care is relevant throughout the continuum of illness, costs are particularly high during the last year of life5—and if the value of certain interventions, such as screening for colorectal cancer, does not accrue for many years, then life expectancy should be considered when deciding to screen. In addition, palliative care can expand the population health toolkit of interventions. Although morbidity and mortality are often attributable to social determinants of health, many problems that palliative care deals with involve social or psychoemotional concerns. For instance, an adult child’s ability to support a parent with Alzheimer disease, or a patient’s resilience in the face of pancreatic cancer, can be improved or strengthened with social, behavioral, and environmental interventions. More broadly, palliative care could expand the reach of population health interventions beyond prevention of illness by developing strategies to improve well-being after an illness has occurred. What Palliative Care Can Learn From Population Health Palliative care also could benefit by incorporating the approaches of population health. For instance, population health models could help palliative care move beyond the current model of inpatient and outpatient consultations. Specialized palliative care clinicians are in short supply, and a population health–based approach may offer novel strategies to meet patients’ and families’ needs without relying on the services of palliative care consultants. This might take the form of more intensive efforts to educate other health care professionals in palliative care (so-called primary palliative care education). It also could include patient education, telehealth, redesign of the electronic medical record to yield actionable data that will improve quality of patient care, and system interventions through application of quality improvement. A population health–based approach and its emphasis on prevention could also encourage palliative care to move “upstream,” reaching individuals earlier in the course of illness. That might include innovative approaches to improving care through social media, education, and peer networks. It also might include efforts to encourage more realistic views of health care and aggressive treatment in the same way that public health interventions have shaped cultural views about smoking or obesity. Population-Based Palliative Care The goal of population-based palliative care should be to promote optimal well-being in the face of serious, life-threatening illness for patients and their families. This vision is based on the World Health Organization’s 1946 definition of health as “complete physical, mental and social well-being.”6 However, population-based palliative care expands that definition to include members of an individual’s social circle who are also affected by an illness. At a minimum, population-based palliative care should include access to specialized palliative care services. These should include both inpatient and outpatient consultative services, as well as palliative home care and hospice. As the United States moves to capitated payment models, access to high-quality palliative care must be preserved. That will require structures of financing and payment that provide adequate support as well as robust evidence that palliative care interventions are cost-effective in achieving outcomes important to patients. Second, population-based palliative care will need to emphasize primary palliative care. Frontline practitioners must be able to deliver key elements of palliative care including prognostication, goals discussions, and symptom management. These skills need not be at the level that palliative care specialists can provide, but patients need to be able to rely on a level of competence regardless of their illness or location. Third, population-based palliative care will need structures that support palliative care in communities and populations. These will include laws that facilitate advance care planning and orders for life-sustaining treatment (eg, POLST forms), as well as laws and employer policies that support family leave to care for seriously ill relatives. Mechanisms of financing are also needed to support the development and evaluation of new models of care, particularly home-based palliative care. Fourth, population-based palliative care will need to find innovative ways to change the culture of serious illness and end-of-life care. At a very basic level, this might include efforts to encourage patients and their families to expect higher standards of communication, shared decision making, and symptom management. Culture change should also include increased openness about serious illness and death, perhaps through community engagement efforts such as the “Before I Die…” participatory art project.7 Last, successful population-based palliative care will require data that provide a picture of a population’s well-being in the face of serious illness. Statistics that define morbidity and mortality will need to be supplemented by other measures that provide a more comprehensive and holistic picture of life with serious illness. These might include measures of time spent in the preferred setting of care in the last month of life, burdensome transitions,8 symptom burden, the financial effects of illness on patients, and caregiving burden. Conclusions Every day, approximately 10 000 people qualify for Medicare. It is essential to begin to transform the health care system from the original 1965 version of Medicare that focused on payment for acute treatment, to a system of payment that ensures competent, coordinated, and compassionate health care for persons with prolonged periods of functional impairment during the last years of their lives. That will require a shift from fee-for-service reimbursement that rewards volume to incentives for improving health of populations. To achieve that goal, population health needs palliative care, and palliative care needs population health. The strengths of both are gaining attention, and each is increasingly aligned with health care financing priorities. The potential synergies of collaborations between the 2 disciplines can advance the agendas of both. Back to top Article Information Corresponding Author: David Casarett, MD, MA, University of Pennsylvania Perelman School of Medicine, 3615 Chestnut St, Philadelphia, PA 19119 (casarett@mail.med.upenn.edu). Published Online: May 12, 2016. doi:10.1001/jama.2016.5961. Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. References 1. Kindig D, Stoddart G. What is population health? Am J Public Health. 2003;93(3):380-383.PubMedGoogle ScholarCrossref 2. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759-769.PubMedGoogle ScholarCrossref 3. Washington AE, Coye MJ, Boulware LE. Academic health systems’ third curve: population health improvement. JAMA. 2016;315(5):459-460.PubMedGoogle ScholarCrossref 4. Kindig D. What Are We Talking About When We Talk About Population Health? Health Affairs Blog website. http://healthaffairs.org/blog/2015/04/06/what-are-we-talking-about-when-we-talk-about-population-health/. April 6, 2015. Accessed May 2, 2016. 5. Krumholz HM, Nuti SV, Downing NS, Normand SL, Wang Y. Mortality, hospitalizations, and expenditures for the Medicare population aged 65 years or older, 1999-2013. JAMA. 2015;314(4):355-365.PubMedGoogle ScholarCrossref 6. Grad FP. The Preamble of the Constitution of the World Health Organization. Bull World Health Organ. 2002;80(12):981-984.PubMedGoogle Scholar 7. Before I Die… website. http://www.beforeidie.cc. Accessed April 15, 2016. 8. Teno JM, Gozalo PL, Bynum JPW, et al. Change in end-of-life care for Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009. JAMA. 2013;309(5):470-477.PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

Why Population Health and Palliative Care Need Each Other

JAMA , Volume 316 (1) – Jul 5, 2016

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Publisher
American Medical Association
Copyright
Copyright © 2016 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.2016.5961
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Abstract

Two evolving disciplines in medicine have brought new ways of thinking about health and disease. One is palliative care, which focuses on improving the quality of life of patients with serious illnesses and their families. A second is population health, which focuses on improving the health of populations, with a special emphasis on reducing disparities in health outcomes and improving the value of health care. Although palliative care and population health are related, there has been limited discussion about how these 2 disciplines can support and complement each other. This synergy is key to improving the quality of care of frail older persons with chronic, life-limiting illnesses. In this Viewpoint, we describe the potential synergies between these 2 disciplines and propose next steps to foster collaboration. What Population Health Can Learn From Palliative Care The concept of population health is not new,1 but it has gained increasing attention in conjunction with the triple aim.2 More recently, its integration into the Affordable Care Act has increased the national prominence of population health.3 As population health develops, there are several ways that it could be strengthened by adding elements of palliative care. For instance, palliative care focuses on patient-centered outcomes such as quality of life, symptom burden, emotional and spiritual well-being, caregiver burden, and bereavement. This more inclusive approach complements the traditional emphasis of population health on reducing morbidity and avoiding mortality. Palliative care can also contribute a frank and open discussion about the value of treatment near the end of life. This is particularly relevant to population health management (also known as “population medicine”), which focuses on improving the health of clinically defined groups.4 Although the value of health care is relevant throughout the continuum of illness, costs are particularly high during the last year of life5—and if the value of certain interventions, such as screening for colorectal cancer, does not accrue for many years, then life expectancy should be considered when deciding to screen. In addition, palliative care can expand the population health toolkit of interventions. Although morbidity and mortality are often attributable to social determinants of health, many problems that palliative care deals with involve social or psychoemotional concerns. For instance, an adult child’s ability to support a parent with Alzheimer disease, or a patient’s resilience in the face of pancreatic cancer, can be improved or strengthened with social, behavioral, and environmental interventions. More broadly, palliative care could expand the reach of population health interventions beyond prevention of illness by developing strategies to improve well-being after an illness has occurred. What Palliative Care Can Learn From Population Health Palliative care also could benefit by incorporating the approaches of population health. For instance, population health models could help palliative care move beyond the current model of inpatient and outpatient consultations. Specialized palliative care clinicians are in short supply, and a population health–based approach may offer novel strategies to meet patients’ and families’ needs without relying on the services of palliative care consultants. This might take the form of more intensive efforts to educate other health care professionals in palliative care (so-called primary palliative care education). It also could include patient education, telehealth, redesign of the electronic medical record to yield actionable data that will improve quality of patient care, and system interventions through application of quality improvement. A population health–based approach and its emphasis on prevention could also encourage palliative care to move “upstream,” reaching individuals earlier in the course of illness. That might include innovative approaches to improving care through social media, education, and peer networks. It also might include efforts to encourage more realistic views of health care and aggressive treatment in the same way that public health interventions have shaped cultural views about smoking or obesity. Population-Based Palliative Care The goal of population-based palliative care should be to promote optimal well-being in the face of serious, life-threatening illness for patients and their families. This vision is based on the World Health Organization’s 1946 definition of health as “complete physical, mental and social well-being.”6 However, population-based palliative care expands that definition to include members of an individual’s social circle who are also affected by an illness. At a minimum, population-based palliative care should include access to specialized palliative care services. These should include both inpatient and outpatient consultative services, as well as palliative home care and hospice. As the United States moves to capitated payment models, access to high-quality palliative care must be preserved. That will require structures of financing and payment that provide adequate support as well as robust evidence that palliative care interventions are cost-effective in achieving outcomes important to patients. Second, population-based palliative care will need to emphasize primary palliative care. Frontline practitioners must be able to deliver key elements of palliative care including prognostication, goals discussions, and symptom management. These skills need not be at the level that palliative care specialists can provide, but patients need to be able to rely on a level of competence regardless of their illness or location. Third, population-based palliative care will need structures that support palliative care in communities and populations. These will include laws that facilitate advance care planning and orders for life-sustaining treatment (eg, POLST forms), as well as laws and employer policies that support family leave to care for seriously ill relatives. Mechanisms of financing are also needed to support the development and evaluation of new models of care, particularly home-based palliative care. Fourth, population-based palliative care will need to find innovative ways to change the culture of serious illness and end-of-life care. At a very basic level, this might include efforts to encourage patients and their families to expect higher standards of communication, shared decision making, and symptom management. Culture change should also include increased openness about serious illness and death, perhaps through community engagement efforts such as the “Before I Die…” participatory art project.7 Last, successful population-based palliative care will require data that provide a picture of a population’s well-being in the face of serious illness. Statistics that define morbidity and mortality will need to be supplemented by other measures that provide a more comprehensive and holistic picture of life with serious illness. These might include measures of time spent in the preferred setting of care in the last month of life, burdensome transitions,8 symptom burden, the financial effects of illness on patients, and caregiving burden. Conclusions Every day, approximately 10 000 people qualify for Medicare. It is essential to begin to transform the health care system from the original 1965 version of Medicare that focused on payment for acute treatment, to a system of payment that ensures competent, coordinated, and compassionate health care for persons with prolonged periods of functional impairment during the last years of their lives. That will require a shift from fee-for-service reimbursement that rewards volume to incentives for improving health of populations. To achieve that goal, population health needs palliative care, and palliative care needs population health. The strengths of both are gaining attention, and each is increasingly aligned with health care financing priorities. The potential synergies of collaborations between the 2 disciplines can advance the agendas of both. Back to top Article Information Corresponding Author: David Casarett, MD, MA, University of Pennsylvania Perelman School of Medicine, 3615 Chestnut St, Philadelphia, PA 19119 (casarett@mail.med.upenn.edu). Published Online: May 12, 2016. doi:10.1001/jama.2016.5961. Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. References 1. Kindig D, Stoddart G. What is population health? Am J Public Health. 2003;93(3):380-383.PubMedGoogle ScholarCrossref 2. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759-769.PubMedGoogle ScholarCrossref 3. Washington AE, Coye MJ, Boulware LE. Academic health systems’ third curve: population health improvement. JAMA. 2016;315(5):459-460.PubMedGoogle ScholarCrossref 4. Kindig D. What Are We Talking About When We Talk About Population Health? Health Affairs Blog website. http://healthaffairs.org/blog/2015/04/06/what-are-we-talking-about-when-we-talk-about-population-health/. April 6, 2015. Accessed May 2, 2016. 5. Krumholz HM, Nuti SV, Downing NS, Normand SL, Wang Y. Mortality, hospitalizations, and expenditures for the Medicare population aged 65 years or older, 1999-2013. JAMA. 2015;314(4):355-365.PubMedGoogle ScholarCrossref 6. Grad FP. The Preamble of the Constitution of the World Health Organization. Bull World Health Organ. 2002;80(12):981-984.PubMedGoogle Scholar 7. Before I Die… website. http://www.beforeidie.cc. Accessed April 15, 2016. 8. Teno JM, Gozalo PL, Bynum JPW, et al. Change in end-of-life care for Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009. JAMA. 2013;309(5):470-477.PubMedGoogle ScholarCrossref

Journal

JAMAAmerican Medical Association

Published: Jul 5, 2016

Keywords: end-of-life care,palliative care

References