Best Practice: Improving End-of-Life Health Care By Incentivizing Goals
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 with a patient in an emergency department is delicate and time-consuming,” said 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,” Carr said.
Read the entire case study on the S.C. Hospital Association website. >>
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 pointed 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."
She added, "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.