Advancing Primary Palliative Care

Palliative care leaders and advocates have been warning for years that there are too few palliative specialists to support the growing number of people diagnosed with serious illnesses – and that making sure generalist clinicians have basic palliative care skills will help fill the gap.

That solution, called primary palliative care, equips frontline clinicians such as family doctors, hospitalists, and oncologists, with deeper skills in communication, pain and symptom management, and psychosocial-spiritual support – all key domains of palliative care.

If frontline clinicians can learn and implement those skills to better support patients with serious illnesses, then specialized palliative care teams can be reserved for the most difficult and complicated cases.

But getting widespread adoption by frontline physicians, nurse practitioners, and physician assistants has been challenging, experts agree. Many resist the idea they have anything to learn. Others say they’re just too busy or can’t fit any more into squeezed primary care appointments. And many still don’t understand what palliative care is and why it’s so important.

Over the past few years, several primary palliative care training programs have emerged to provide much-needed education and grow awareness, and some have had notable success. But there’s still a long road ahead.

A Commitment to Primary Palliative Care

California took a big step forward in expanding access to palliative care in 2014 when legislators approved SB 1004, directing the state Department of Health Care Services (DHCS) to provide technical assistance to Medi-Cal managed care plans in providing palliative care services.

Jennifer Moore Ballentine
Jennifer Moore Ballentine

In 2018, the same bill funded a $250,000 contract with the California State University Shiley Institute for Palliative Care to provide free courses – including self-paced primary palliative care training – to Medi-Cal providers across the state.

Enrollment in those DHCS-covered courses exceeded 240 over an 18-month period, said the Institute’s Executive Director Jennifer Moore Ballentine. And earlier this year, when the COVID-19 pandemic emerged, the Institute offered about 20 courses – including some in primary palliative care – at no cost to health professionals on the front lines, logging more than 5,000 enrollments over 3 months from clinicians all over the world.

Still, there are more than 141,000 licensed physicians, nurse practitioners, and physician assistants practicing in California alone, according to a 2017 report from the California Health Care Foundation. Getting broad adoption of primary palliative care training and implementation – not just in California but across the country – is a challenge the whole field is determined to address, Ballentine said.

“How do we put across the importance of palliative care in every medical setting, every encounter?” she said. “We have to figure out where are the most productive places to start – where do we need to go to make the most impact and put across our message in ways likely to succeed?”

She said the Institute is wrapping up a significant update of its online self-paced primary palliative care curriculum – which includes courses on communication and advance care planning, physical aspects of care, spiritual and emotional support, and integrating palliative care into practice – with the goal of rolling it out to additional states and health systems.

The Institute isn’t alone. The Center to Advance Palliative Care (CAPC), VitalTalk, Ariadne Labs, and others also offer training focused on primary palliative care and/or specific strategies frontline clinicians can use to support patients with serious illness.

Using Palliative Specialists as Educators

In Oregon, Providence Health & Services has demonstrated its commitment to primary palliative care with a staff training program that supports frontline palliative care “champions” at participating clinics and includes mentorship from palliative care specialists within the regional health system.

Caroline Hurd
Caroline Hurd, MD

“We have an education team that partners with the frontline champions and we will train the entire clinic—from front desk to prescribing providers,” said Caroline Hurd, MD, part of the system’s Palliative Care Connections education team.

“I’m a strong believer in primary palliative care, and 100 percent of my time with Providence is now devoted to education,” says Dr. Hurd, who is also on the faculty of the University of Washington, Seattle.

“As we expand the number of clinic champions, we’re expanding our educational support team model as well,” Hurd said. Lessons led by palliative specialists are incorporated into regular staff meetings and the training incudes an emphasis on changing the clinic culture to integrate what’s being learned, with skill-based practice using VitalTalk principles.

The model, supported by the Cambia Foundation, is interprofessional, with everyone on the palliative care team expected to contribute. Team members have between 20 and 60 percent of their FTEs protected for education, and clinic champions have 5 to 10 percent of their time protected to support clinic initiatives.

Ten clinic champions have been trained to date—doctors, physician assistants, nurse practitioners, social workers and psychologists.

“These folks work within their clinic and serve as champions of palliative care for the rest of the clinicians,” Hurd said.

In the sites where they are based, rates of advance care planning and documented goals of care conversations have skyrocketed, she said.

Some experts believe the COVID-19 pandemic may have led to a turning point in helping generalist clinicians understand exactly what palliative care is and why it’s needed.

“When I was first working in this field and I’d try to describe what palliative care is, I’d get expressions of furrowed brows, (like) ‘Isn’t that what doctors do anyway?’” Ballentine recalled. “To put across that this is a new skill set, beyond what doctors already do, is a constant challenge.”

But because palliative care clinicians are experts in sharing serious news and providing whole-person support to patients and families, they’ve been relied on heavily during this pandemic, Ballentine noted.

“Any frontline clinician who observed a palliative care professional at work in the crisis would come away with a new appreciation of what it offers,” she said.

Hurd said in the Providence program, boots-on-the-ground guidance from palliative care specialists helps frontline providers understand how to integrate what they’re learning into what may be an overburdened primary care practice. Ultimately, the practice, the patients, and the clinicians all benefit.

“The time pressure on clinicians in primary care is incredible,” Hurd said. “We want to help (them) see that learning these new skills is an investment in their own resilience. We often hear clinicians who have learned primary palliative care say, ‘I feel connected to my patients once again.’”

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