A Model to Improve Hospital-Based Palliative Care: The Palliative Care Redistribution Integrated System Model (PRISM)
Many hospitalized patients have unmet palliative care needs that are exacerbated by gaps in the palliative care subspecialty workforce. Training frontline physicians, including hospitalists, to provide primary palliative care has been proposed as one solution to this problem. However, improving palliative care access requires more than development of the physician workforce. System-level change and interdisciplinary approaches are also needed. Using task shifting as a guiding principle, we propose a new workforce framework (the Palliative care Redistribution Integrated System Model, or PRISM), which utilizes physician and nonphysician providers and resources to their maximum potential. We highlight the central role of hospitalists in this model and provide examples of innovations in screening, workflow, quality, and benchmarking to enable hospitalists to be purveyors of quality palliative care.
© 2018 Society of Hospital Medicine
Palliative care is an essential component of inpatient medicine. At its core, it is an interdisciplinary philosophy of care aiming to achieve the best quality of life for patients and families in the physical, psychosocial, and spiritual domains. With the aging population and growing complexity of hospitalized patients, inpatient palliative care needs are only projected to rise. However, a mismatch exists between the number of palliative care–trained physicians and the demand for such physicians. Currently, only 6,600 US physicians are board certified in palliative care – just 37% of the projected need.1 These workforce shortages have serious implications. In fact, it is estimated that nearly 40% of all hospitalized patients who need palliative care go without it.2
Existing efforts to improve access to palliative care have largely focused on bolstering the palliative care workforce. One tactic particularly relevant to hospitalists centers on frontline physicians providing “primary” palliative care: basic symptom management, patient-centered communication, and goals of care assessment, regardless of the disease state.3 Such physicians constitute the base of today’s palliative care workforce model – a three-tiered pyramid built on clinician availability and skills. In this model, the second tier (“secondary” palliative care) includes physicians supported by a palliative care consultant or referral. The third level (“tertiary” palliative care) encompasses care provided directly by specialized palliative care teams, usually within academic medical centers (Figure).4
The practice of primary palliative care is central to the practice of hospital medicine.5,6 After all, hospitalists generate nearly half of all inpatient palliative care consultations7 and routinely interface with social workers, pharmacists, nurses, chaplains, and other consultants in their daily activities. Consequently, they are also well versed in serious illness communication and prognostication.8 In many ways, they are ideal purveyors of palliative care in the hospital.
Why then does the challenge to meet the demands of patients with palliative care needs persist? The truth may lie in at least three central shortcomings within the tiered palliative care workforce model. First, physicians comprising the base (where hospitalists typically fall) possess variable skills and knowledge in caring for seriously ill patients. While training opportunities exist for interested individuals,7 education alone can rarely achieve a systematic change. Second, some physicians may have the requisite skills but lack
