Read about the California HealthCare Foundation’s effort to be a catalyst for change in this area.

While access to palliative care has been steadily increasing in hospital settings over the past decade, a survey published in 2007 on the availability of palliative care in California and funded by the California HealthCare Foundation (CHCF), found that only 33 percent of all California hospitals reported a palliative care consulting service. The situation for public hospitals was even worse, with only 20 percent of such hospitals in California offering a palliative care consulting service at that time.

Palliative care–as described by the Center to Advance Palliative Care–is the medical specialty focused on improving the overall quality of life for people facing serious and life-threatening illness. Palliative care emphasizes pain and symptom control, intensive communication (including family support and shared decision making), and coordination of care. Although palliative care is often associated with end-of-life care, its availability does not depend on a patient’s prognosis.

The substantial barriers to the expansion of palliative care in California public hospitals include a patient population that is poor and medically underserved; relentless change in hospitals’ fiscal and regulatory policy environments; and the linguistic diversity of patients in these hospitals, where English is sometimes a minority language among the dozens of languages spoken.

Recognizing the need to expand the availability of palliative care in public hospitals, despite these obstacles, in 2009 the CHCF awarded grants to start a palliative care consultation service at eight public hospitals and expansion grants to extend existing programs at four hospitals.

When palliative care services are up and running, providers working with patients who have severe and life-threatening illnesses can call upon trained palliative care teams that will consult with them, and with patients and families, to reach consensus about how much and what kinds of medical interventions are desired. This process of developing an agreed-upon roadmap for treatment sounds natural–yet in hospitals where the default is often to treat all patients with every tool in the arsenal, regardless of the stage and degree of illness, reaching an informed decision about treatment through palliative care consultations is often a revolutionary process.

A recent interim evaluation report indicates that the CHCF has helped to serve as a catalyst to expand the number of high-quality palliative services in California public hospitals; through its funding, the hospitals have already served more than 3,400 patients. These services meet national standards and indicators of quality in palliative care. For example, they are integrated into the hospitals’ quality improvement measures and report both program and financial data. They also provide educational material in multiple languages and hold meetings with palliative care team members, patients, and families to discuss the goals of care and mutually determine best approaches to achieve comfort for patients.

The CHCF’s multifaceted approach to starting and advancing palliative care in public hospitals–which includes financial support, technical assistance, and a peer-learning community–appears to be successfully building palliative care capacity in such hospitals. The CHCF recipe for building that capacity has included the following ingredients:

(1) Build a knowledge base. First, using a series of CHCF surveys and reports, the foundation created a publicly available “library” of information and tools about palliative care, which is available on the CHCF website.

(2) Start with planning grants. An initial series of planning grants enabled hospitals to research and plan for what would be required to implement palliative care programs in their unique settings and to participate in the Palliative Care Leadership Center training at the University of California, San Francisco. It is one of eight leadership centers supported by a consortium of funders and affiliated with the Center to Advance Palliative Care.

(3) Provide substantial expansion and implementation grants. CHCF grants were awarded in 2009 and early 2010 to twelve hospitals so that they could either expand their existing palliative care services (four hospitals), or implement new services (eight hospitals). This round of funding reached twelve of the seventeen acute care hospital members (70 percent) of the California Association of Public Hospitals and Health Systems. The CHCF authorized another round of implementation grants in December 2010 for up to five hospitals. Hospitals are now in the process of responding to a request for proposals. If all are funded, then all acute care public hospitals in California would provide palliative care programs at the conclusion of the CHCF’s initiative.

(4) Support grantees with technical assistance. Implementation and expansion grants are supported by multiple types of technical assistance from the Palliative Care Leadership Center at UCSF. All grantee sites participate in multiple-day trainings at UCSF and have subsequent access to ongoing technical support from center staff.

(5) Mandate sites to develop a fiscal sustainability plan. An important aspect of UCSF’s technical assistance shows sites how to demonstrate financial savings from their palliative care services to help them make the financial case for sustaining these services. In addition, the California Health Care Safety Net Institute (the research and educational affiliate of the California Association of Public Hospitals and Health Systems), a key partner with the CHCF in working with the public hospitals, helps sites build their visibility through their relationships with public hospitals’ leadership.

(6) Gather data for collective learning. Sites collect common data to document their work, growth of palliative care services over time, and how the services fit within the larger hospital context. Data are shared across sites for benchmarking and mutual learning.

(7) Create a learning community. All sites participate in monthly calls and an annual meeting to discuss common topics of interest with experts— including pain management, integrating chaplaincy services into palliative care teams, and developing self-care programs to avoid provider burn-out—and to share case studies.

(8) Improve medical interpretation for palliative care. Interpreting palliative care consultations is very demanding, and many medical interpreters feel that specialized training would enhance these discussions. To address the needs of public hospitals, which see such a large percentage of non-English speakers, the CHCF is funding a national survey of medical interpreters to explore where additional training may be useful to interpreters. An educational program to prepare interpreters for the palliative care encounter is being developed; it will be available for face-to-face training in 2011, with plans to make the training available online as well.

(9) Fund an evaluation. The evaluation is documenting and summarizing the work of sites to tell the story of implementing palliative care in California’s public hospitals.

Still, many challenges remain. While the number of palliative care services continues to grow, they are still insufficient to meet the demand. Among the biggest concerns that sites have are their hospitals’ ongoing budget challenges and their palliative care teams being unable to manage the increased demand for their services once the word is out that they exist.

This initiative is still mid-course, and final results are not in. However, it appears that there is reason for optimism about the effectiveness of this approach to assuring that low-income, uninsured, and underinsured patients, many of whom have long-neglected medical and other needs, receive the best possible care while they face serious decisions about health care and the quality of their lives and deaths.