Networking Opens Doors for Palliative Care, Say Doctors in Rural Practices

Abstract

Kerri Wachter is a senior writer with Elsevier Global Medical News.TAMPA — It's not easy to practice palliative medicine in rural areas, but it's possible—with creativity, persistence, and retraining, according to two physicians who have switched from other specialties.“The take-home message is that you can be retraining and working in this field at the same time,” said Dr. Tina L. Smusz, a one-time emergency medicine specialist who is now the medical codirector of Carilion Hospice of New River Valley Medical Center, Christiansburg, Va. She and Dr. Christopher W. Pile of Carilion Roanoke (Va.) Memorial Hospital described their experiences recently at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.Retraining might be one way to ease the growing need for palliative care specialists, according to Dr. Edward Vandenberg, CMD, of the department of geriatrics at the University of Nebraska, Omaha. “The need for palliative care services in rural areas will rapidly outpace the need in urban areas on a per-person basis. Rural nursing homes will carry a significant share of the burden,” he said in an interview.The percentage of individuals over age 65 years who live in rural areas and need chronic care exceeds the percentage in urban areas. In 2004, the proportion of the population over age 65 years in the United States was 12.1%, while the proportion in rural Nebraska, for example, was 17%.Both Dr. Smusz and Dr. Pile said that they were able to start practicing palliative medicine—while still learning how to provide it—by establishing relationships with several facilities in Southwestern Virginia simultaneously.Dr. Pile was a practicing family physician when he started as the volunteer director of palliative care at Wythe County Community Hospital and its Hospice of Southwest Virginia. The area served by the hospice and the 104-bed acute and subacute care hospital includes four counties that have a total population of about 120,000.Dr. Pile became the hospice's medical director and chairman of the hospital's ethics committee. After becoming certified in palliative medicine by the American Board of Hospice and Palliative Medicine, he gained consulting privileges in palliative care at Smyth County Community Hospital in Marion, Va., and Johnston Memorial Hospital in Abingdon, Va., where he also had contracts for delivering palliative care and ethics administration.Setting up the contracts was important because they allowed him to be paid for administrative time. Dr. Pile advised his audience to ensure that they are compensated for administrative time. “Don't shortchange yourself. [About] $100 an hour is reasonable,” he said.He also became medical director of Valley Health Care Center, a 180-bed nursing facility in Chilhowie, Va., that offers skilled, intermediate, and assisted living care. He also became an associate professor at the Virginia College of Osteopathic Medicine in Blacksburg.All of these entities supported his training and contribute to his current compensation. “Really it's just a matter of being creative,” said Dr. Pile. For instance, when he travels to palliative care training symposia, one facility pays for airfare, another facility covers registration, and a third reimburses his hotel costs. In return, Dr. Pile said he brings what he has learned back to each facility and gives in-service training to every staff member.Dr. Pile's training has included a course based on the Education on Palliative and End-of-Life Care project, the American Academy of Hospice and Palliative Medicine's hospice medical director course and current concepts in palliative care course, and Harvard Medical School's program in palliative care education and practice. He also received palliative care leadership training under the auspices of the Center to Advance Palliative Care.Dr. Smusz also works with several facilities in Virginia. Besides holding the post as medical codirector of Carilion Hospice of the New River Valley, she is a palliative medicine specialist there and does inpatient consultation for the larger network of facilities called Carilion Clinic. She also is an associate professor with the Virginia College of Osteopathic Medicine. The area served by the Carilion Hospice includes four counties with a total population of more than 150,000.Once Dr. Smusz realized that she had an interest in palliative medicine, she began volunteering with the hospice and doing home visits while continuing to work in emergency medicine. She became medical codirector of the hospice while she was still retraining. The following year she started to do palliative medicine consultations at Carilion New River Valley Medical Center.Her training included a Center to Advance Palliative Care course on building a hospital-based palliative care program, training in one of the center's palliative care leadership programs, the same Education on Palliative and End-of-Life-Care course and Harvard program in palliative care education and practice that Dr. Pile attended. She also did extensive study on her own.Dr. Smusz paid for her initial training herself, but made the money she needed by starting hospice work while in her retraining period. She was able to pull together additional funding from the facilities that she was working with. “Once people see that there's success, they want to start adding to that,” she said.“Dr. Pile and Dr. Smusz have demonstrated an innovative approach to delivery of palliative care by combining the roles of the practice of palliative medicine with medical directorships of hospices and nursing homes,” said Dr. Vandenberg. “For the nursing home, this approach would provide skills and knowledge along with leadership in an area that critically needs improved end-of-life care. Through the medical directorship position, these physicians will not only have the ability to provide expertise in palliative care but also make system changes through quality improvement activities in end-of-life care in the nursing home. Finally, to provide this expertise in a rural environment addresses the areas that need it most.”For anyone interested in making the transition to palliative care, Dr. Smusz recommended starting at a hospice. “You need to learn frontline … care of dying people before you ever pretend that you know how to do palliative medicine,” she said.“The thing that makes this work is the teams,” said Dr. Pile. At every facility, a palliative care specialist should assemble a team made up of interested people from various disciplines—respiratory therapists, social workers, administrators, physicians, and nurses. It's the support of these teams that has allowed Dr. Pile to cover a broad geographic area, he said.Much emotional support also comes from colleagues he met during training who now are in similar positions. “Those relationships were critical and fundamental to success,” said Dr. Pile.Dr. Smusz agreed, “If you can find one other person in your area, that helps tremendously.”Dr. Pile said it is important for a palliative care specialist to regularly reinforce his or her value to rural facilities. He recommended keeping records of the annual number of patient-days spent in hospice and the average number of referrals made to hospice per month for each facility. Data such as these can demonstrate to administrators that having a palliative care specialist available can generate income from hospice services.Dr. Smusz agreed that administrators need to be reminded periodically of the impact that a palliative care specialist can have on a facility's bottom line. Initially, she simply shared case reports with her administrators, but then she began generating data that could show, for instance, billable hospice days per year and average cost of care before and after a palliative care referral.Physicians who branch out from their routines to be involved in hospice care should learn to promote themselves and their special skills, said Dr. Smusz. “Many of us are not used to getting out there and promoting ourselves,” she said, but physicians should remember that “any self-promotion that you're doing is focused on how you can help these patients.”Physicians interested in entering palliative medicine have a 5-year window in which they can become certified without the requirement for a formal fellowship. Beginning this year, cooperating boards within the American Board of Medical Specialties will offer a subspecialty certificate in hospice and palliative medicine.Through 2012, candidates without formal training through a fellowship in hospice and palliative medicine may sit for examination if they have prior certification by the American Board of Hospice and Palliative Medicine or have had at least 800 hours of subspecialty-level practice in hospice and palliative medicine during the past 5 years.That experience must include at least 2 years and 100 hours of participation with a hospice or palliative care team and active care of at least 50 terminally ill adult patients or 25 pediatric patients. For more information, see the American Academy of Hospice and Palliative Medicine's certification Web site (www.aahpm.org/certification/abms.html). Dr. Pile and Dr. Smusz said they have no relevant financial relationships to disclose. Kerri Wachter is a senior writer with Elsevier Global Medical News. TAMPA — It's not easy to practice palliative medicine in rural areas, but it's possible—with creativity, persistence, and retraining, according to two physicians who have switched from other specialties. “The take-home message is that you can be retraining and working in this field at the same time,” said Dr. Tina L. Smusz, a one-time emergency medicine specialist who is now the medical codirector of Carilion Hospice of New River Valley Medical Center, Christiansburg, Va. She and Dr. Christopher W. Pile of Carilion Roanoke (Va.) Memorial Hospital described their experiences recently at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association. Retraining might be one way to ease the growing need for palliative care specialists, according to Dr. Edward Vandenberg, CMD, of the department of geriatrics at the University of Nebraska, Omaha. “The need for palliative care services in rural areas will rapidly outpace the need in urban areas on a per-person basis. Rural nursing homes will carry a significant share of the burden,” he said in an interview. The percentage of individuals over age 65 years who live in rural areas and need chronic care exceeds the percentage in urban areas. In 2004, the proportion of the population over age 65 years in the United States was 12.1%, while the proportion in rural Nebraska, for example, was 17%. Both Dr. Smusz and Dr. Pile said that they were able to start practicing palliative medicine—while still learning how to provide it—by establishing relationships with several facilities in Southwestern Virginia simultaneously. Dr. Pile was a practicing family physician when he started as the volunteer director of palliative care at Wythe County Community Hospital and its Hospice of Southwest Virginia. The area served by the hospice and the 104-bed acute and subacute care hospital includes four counties that have a total population of about 120,000. Dr. Pile became the hospice's medical director and chairman of the hospital's ethics committee. After becoming certified in palliative medicine by the American Board of Hospice and Palliative Medicine, he gained consulting privileges in palliative care at Smyth County Community Hospital in Marion, Va., and Johnston Memorial Hospital in Abingdon, Va., where he also had contracts for delivering palliative care and ethics administration. Setting up the contracts was important because they allowed him to be paid for administrative time. Dr. Pile advised his audience to ensure that they are compensated for administrative time. “Don't shortchange yourself. [About] $100 an hour is reasonable,” he said. He also became medical director of Valley Health Care Center, a 180-bed nursing facility in Chilhowie, Va., that offers skilled, intermediate, and assisted living care. He also became an associate professor at the Virginia College of Osteopathic Medicine in Blacksburg. All of these entities supported his training and contribute to his current compensation. “Really it's just a matter of being creative,” said Dr. Pile. For instance, when he travels to palliative care training symposia, one facility pays for airfare, another facility covers registration, and a third reimburses his hotel costs. In return, Dr. Pile said he brings what he has learned back to each facility and gives in-service training to every staff member. Dr. Pile's training has included a course based on the Education on Palliative and End-of-Life Care project, the American Academy of Hospice and Palliative Medicine's hospice medical director course and current concepts in palliative care course, and Harvard Medical School's program in palliative care education and practice. He also received palliative care leadership training under the auspices of the Center to Advance Palliative Care. Dr. Smusz also works with several facilities in Virginia. Besides holding the post as medical codirector of Carilion Hospice of the New River Valley, she is a palliative medicine specialist there and does inpatient consultation for the larger network of facilities called Carilion Clinic. She also is an associate professor with the Virginia College of Osteopathic Medicine. The area served by the Carilion Hospice includes four counties with a total population of more than 150,000. Once Dr. Smusz realized that she had an interest in palliative medicine, she began volunteering with the hospice and doing home visits while continuing to work in emergency medicine. She became medical codirector of the hospice while she was still retraining. The following year she started to do palliative medicine consultations at Carilion New River Valley Medical Center. Her training included a Center to Advance Palliative Care course on building a hospital-based palliative care program, training in one of the center's palliative care leadership programs, the same Education on Palliative and End-of-Life-Care course and Harvard program in palliative care education and practice that Dr. Pile attended. She also did extensive study on her own. Dr. Smusz paid for her initial training herself, but made the money she needed by starting hospice work while in her retraining period. She was able to pull together additional funding from the facilities that she was working with. “Once people see that there's success, they want to start adding to that,” she said. “Dr. Pile and Dr. Smusz have demonstrated an innovative approach to delivery of palliative care by combining the roles of the practice of palliative medicine with medical directorships of hospices and nursing homes,” said Dr. Vandenberg. “For the nursing home, this approach would provide skills and knowledge along with leadership in an area that critically needs improved end-of-life care. Through the medical directorship position, these physicians will not only have the ability to provide expertise in palliative care but also make system changes through quality improvement activities in end-of-life care in the nursing home. Finally, to provide this expertise in a rural environment addresses the areas that need it most.” For anyone interested in making the transition to palliative care, Dr. Smusz recommended starting at a hospice. “You need to learn frontline … care of dying people before you ever pretend that you know how to do palliative medicine,” she said. “The thing that makes this work is the teams,” said Dr. Pile. At every facility, a palliative care specialist should assemble a team made up of interested people from various disciplines—respiratory therapists, social workers, administrators, physicians, and nurses. It's the support of these teams that has allowed Dr. Pile to cover a broad geographic area, he said. Much emotional support also comes from colleagues he met during training who now are in similar positions. “Those relationships were critical and fundamental to success,” said Dr. Pile. Dr. Smusz agreed, “If you can find one other person in your area, that helps tremendously.” Dr. Pile said it is important for a palliative care specialist to regularly reinforce his or her value to rural facilities. He recommended keeping records of the annual number of patient-days spent in hospice and the average number of referrals made to hospice per month for each facility. Data such as these can demonstrate to administrators that having a palliative care specialist available can generate income from hospice services. Dr. Smusz agreed that administrators need to be reminded periodically of the impact that a palliative care specialist can have on a facility's bottom line. Initially, she simply shared case reports with her administrators, but then she began generating data that could show, for instance, billable hospice days per year and average cost of care before and after a palliative care referral. Physicians who branch out from their routines to be involved in hospice care should learn to promote themselves and their special skills, said Dr. Smusz. “Many of us are not used to getting out there and promoting ourselves,” she said, but physicians should remember that “any self-promotion that you're doing is focused on how you can help these patients.” Physicians interested in entering palliative medicine have a 5-year window in which they can become certified without the requirement for a formal fellowship. Beginning this year, cooperating boards within the American Board of Medical Specialties will offer a subspecialty certificate in hospice and palliative medicine. Through 2012, candidates without formal training through a fellowship in hospice and palliative medicine may sit for examination if they have prior certification by the American Board of Hospice and Palliative Medicine or have had at least 800 hours of subspecialty-level practice in hospice and palliative medicine during the past 5 years. That experience must include at least 2 years and 100 hours of participation with a hospice or palliative care team and active care of at least 50 terminally ill adult patients or 25 pediatric patients. For more information, see the American Academy of Hospice and Palliative Medicine's certification Web site (www.aahpm.org/certification/abms.html). Dr. Pile and Dr. Smusz said they have no relevant financial relationships to disclose. Palliative Care Resources▸ American Academy of Hospice and Palliative Medicine (www.aahpm.org)▸ Center to Advance Palliative Care (www.capc.org)▸ Educating Physicians in End-of-Life Care (www.epec.net/EPEC/webpages/index.cfm)▸ Program in Palliative Care Education and Practice, Harvard Medical School (www.hms.harvard.edu/cdi/pallcare)▸ Palliative Care in the Long-Term Care Setting (www.amda.com)▸ Palliative Care Curriculum Teaching Kit (www.amda.com) ▸ American Academy of Hospice and Palliative Medicine (www.aahpm.org) ▸ Center to Advance Palliative Care (www.capc.org) ▸ Educating Physicians in End-of-Life Care (www.epec.net/EPEC/webpages/index.cfm) ▸ Program in Palliative Care Education and Practice, Harvard Medical School (www.hms.harvard.edu/cdi/pallcare) ▸ Palliative Care in the Long-Term Care Setting (www.amda.com) ▸ Palliative Care Curriculum Teaching Kit (www.amda.com)