Palliative Care and Hospice: Case Managers Face Haunting Challenges

Case managers and physicians approach palliative care from different perspectives.

There are many staffing models for case managers. A number of years ago, the trend leaned toward combining the activities of discharge planning and utilization instead of employing two individuals to look at the same chart.

Recently, the pendulum appears to be swinging back, with many health systems identifying that often, the duties associated with helping patients and families prepare for discharge from the hospital are hindered by the often-difficult conversations regarding utilization management.

Regardless of the model used, hospital case managers charged with assisting patients and families as they navigate down the harrowing road of deciding “what’s next?” face multiple challenges themselves.

One critical challenge comes from the collaboration (or lack thereof) with the patient’s provider. While case managers are having conversations with patients about expectations and wishes for their care, these same discussions may take a very different form when they involve the patient and physician. In fact, some might not be “discussions” at all. Whether due to physician misunderstanding of palliative care and hospice, reluctance to have such a conversation with the patient and family (at times due to a perception of “giving up” on the patient), or uncertainty about continuity of care by adding another provider into the mix, the topic of palliative care can be quickly glossed over – or never brought up at all.

This puts the case manager in a difficult position, both in scenarios in which the patient or family brings the topic up themselves, and when the case manager communicates that he or she feels strongly that palliative care would benefit the patient. While some hospitals allow bedside nurses and case managers to place an order on their own for a palliative care consult, others require the attending physician to place the order. Unfortunately, the latter can result in patients surrounded by a care team, even including other consultant physicians, who all feel strongly that the patient would benefit from a comprehensive discussion about palliative care’s goals and services – but who are powerless to provide it.

Families can also pose significant challenges for case managers and providers when it comes to considering palliative care or hospice. Especially in the acute hospital setting, even if the patient has been hospitalized multiple times before, there is often a sentiment that everything will be fine as soon as the patient recovers and is once again able to be discharged. Even with the best discharge plan put into place for the patient to follow up with their primary provider or a palliative care physician in the outpatient setting, it is not uncommon for patients to be re-hospitalized before this occurs.

Another difficulty with initiating this conversation in the hospital setting is that many times, the patient is being cared for by a hospitalist the patient and family have ever seen before. While hospitalists provide excellent care, and serve as an important bridge for outpatient primary care physicians, they lack the connection to patients created by multiple visits over multiple years.

Some hospitalists have overcome this barrier by evolving into stellar communicators with a strong understanding of palliative care and hospice, and a talent for presenting the information in a manner that patients and families readily interpret as another option for optimizing care. When working within a care team spearheaded by a physician such as this, case managers can simply walk through the door of opportunity created by the hospitalist, as opposed to fumbling with the key in the lock to see if the topic can be broached.

Case managers around the country applaud all initiatives that promote and encourage palliative care and hospice services for their patients, and all of us involved are anxious to see what’s beyond the horizon.