Can Palliative Care Be Provided Entirely From Afar?

Palliative care is a humanistic, patient-centric form of healthcare that includes medical, emotional, and other supportive services for people who are confronting the impacts of a serious illness in many areas of their lives. Some have even called it “hand-holding,” although it involves much more than that.

But since the onset of the COVID pandemic two years ago—and for some providers even before then—virtual connections via FaceTime, Zoom, or other telemedicine options have become a common medium for seeing palliative patients. How to create the virtual equivalent of hand-holding from a distance has been a big question for some palliative care teams.

BJ Miller, MD, palliative care physician, president of Mettle Health
Dr. BJ Miller

“Palliative care is very much about hand-holding, and by that we mean being fully present with someone and all that this entails,” says BJ Miller, MD, a palliative care physician and president of Mettle Health, a virtual palliative care startup based in Mill Valley, Calif. “Touch is very highly regarded in this work. But it turns out you can still do a lot of that online.”

The Mettle Health clinical team—two doctors, a nurse, a social worker, and a chaplain—offers a social service model of support for seriously ill patients and especially for their family caregivers. Unlike hospice or other community-based palliative care services, it does not take on medical management of the patient’s care. “We are more akin to coaching than true palliative medicine,” but still true to the philosophy of palliative care, says Mettle cofounder Sonya Dolan. “That was a choice to enable us to launch the service more quickly.”

Sonya Dolan, Mettle Health cofounder
Sonya Dolan

Currently, Mettle’s service is private pay, direct to consumer, with a fee of $220 for a single consultation, Dolan says. It offers an income-based sliding scale, discounted packages for multiple visits, and a free initial 20-minute consult. The company also offers webinars and aims in time to facilitate group support sessions and offer a self-guided app and a portal for health professionals seeking to connect and interact with one another. Mettle is also getting closer to seeking investors to grow more rapidly and start developing contracts with health plans, insurers, and employers.

“Whatever is lost from not being present physically seems to be made up for in other ways. I get a little window into the patient’s home, as they get a window into mine,” Dr. Miller says. The conversations can get nuanced and complicated; some people find that it feels safer. “And we can go some places online that would be harder to do in person. Our clients would tell you they feel heard in uncommon ways, in ways that didn’t happen in their doctor’s office.”

An Exploding Corporate Sector

While a variety of small palliative care companies like Mettle are emerging, home-based palliative care is also an exploding sector for big insurance companies such as Humana (which bought Kindred at Home), Anthem (which acquired Aspire Healthcare) and United Healthcare (whose Optum division recently added Landmark to its portfolio of home-based products).

Unlike many home- and community-based palliative care providers, which struggle to survive on inadequate fee-for-service billing for their physician visits, the new corporate model is built on value-based contracts for covered lives in need of palliative care as identified via computer algorithms. If the home-based palliative care provider, which typically sends palliative-trained nurse practitioners to the patient’s home, with physician backup, can reduce overall rates of rehospitalizations and emergency room visits and help the patient manage safely at home, everybody wins.

But many palliative care providers also make considerable use of virtual connections, both to minimize possible exposure to COVID and to increase efficiency by curtailing windshield time. ResolutionCare, a palliative care service started in Eureka, Calif., had incorporated a robust online component for several years, but then, when the pandemic hit, pivoted to almost completely virtual connections. ResolutionCare was recently purchased by Vynca, a physician-led palliative care service, as part of the latter’s $30 million expansion with growth capital for building out its palliative care platform—a mix of virtual palliative care, advance care planning, care coordination, and symptom-management services.

But the question still arises, can this kind of service satisfy patient need virtually, with no infrastructure for home visits? If you read accepted definitions of palliative care, they have an incredibly broad mission, Dr. Miller says. “Often my work in a hospital setting is focused more on symptom management, like pain and nausea. But I’ve noticed that in this virtual format I spend more time talking to people about existential and spiritual issues, questions of identity and of meaning, dealing with their emotional and logistical issues.”

Caring Across the Ocean

In 2020, Ashwini Bapat, MD, a palliative care physician practicing in Boston, Mass., moved to Portugal with her husband and two young children. At the same time, she founded a palliative telemedicine company called EpioneMD. Other members of its interdisciplinary team are in the U.S., but Dr. Bapat cares for her American clients via the Internet just as easily from across the Atlantic Ocean, once the five-hour time difference is accounted for. In fact, the differing time zones enable EpioneMD to offer a broader range of available times.

EpioneMD provides two distinct services. One is personal coaching and assistance with advance care planning and serious illness support for individuals living with aging or illness and their caregivers. It is also developing partnerships to provide palliative care consultations to primary care practices and to health facilities, particularly in small or rural hospitals that don’t have an in-house palliative care team.

“We’re not taking the place of in-person medicine but complementing it and providing additional support to patients and caregivers,” Dr. Bapat says. “Whether seeing the person in-person or remotely doesn’t feel dramatically different. Patients can feel just as connected.” Either way it requires building trust and rapport. EpioneMD has started collaborating with local Councils on Aging, senior centers, and South Asian community organizations to increase awareness of palliative care.

There’s a lot of confusion currently about what palliative care is in a post-pandemic world, adds Mettle Health’s Dr. Miller. “With this kind of segmentation, as we keep spinning out these different models, with some subtle and some obvious differences, maybe at some level we’re contributing to the confusion. All we know is that people need more of this kind of support, and we’re hell-bent on making palliative care more accessible.”

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