In this episode, we listen in on a conversation between Mountain Valley Hospice Senior Vice President of Strategy and Innovation, Maria Hayes, and CHESS Health Solutions Senior Director of Clinical Operations, Dr. Kim Vass Eudy, about End of Life Care, the difference between palliative care and hospice care, and how Providers can utilize these services.

KVE: Well, thank you and welcome to the Move to Value podcast. I am really excited to bring a guest with me today. Her name is Maria Hayes. She is the Senior Vice President of Strategy and Innovation at Mountain Valley. I am excited to speak with her because in my clinical team, we are working towards bringing advanced care planning to our value partners and their patients. And Maria and I have been working kind of behind the scenes talking about this. So I really want to bring that conversation out forward Maria and I'm really glad to have you here today.

MH: Thank you. I'm super excited to be here. Thank you for the invitation.

KVE: I was hoping you could kind of kick this off by telling us a little bit about palliative care and Hospice care. I know as a clinician, when I make a referral, sometimes I just do a bucket referral, I say just give them palliative or give them Hospice, whichever one this patient qualifies for. So maybe you could help me understand and our listeners understand the difference between the two.

MH: Absolutely. And I can actually start off by kind of giving you a little bit of an overview about Mountain Valley, if that will be helpful. And then I'll kind of go into Hospice versus palliative care. So, Mountain Valley is a Hospice and palliative care organization serving 18 counties across North Carolina and southwestern Virginia. We were established in 1983, so we just celebrated our 40th anniversary. Headquartered in Dobson, NC, we provide care in a large service area with six Hospice offices, 4 serious illness specialist locations and two inpatient Hospice care centers. We also have two Hospice thrift stores. We call them the Humble Hare and those stores actually benefit our charity care programs.

Palliative care is a little bit different than Hospice care. So palliative care is a specialized medical care for people living with a serious illness. This can be cancer, heart failure, lung disease, dementia, Parkinson's disease or ALS. Patients in palliative care may receive medical care aimed at easing their symptoms along with treatment intended to be aggressive or curative. Palliative care is meant to enhance a person's current care by focusing on quality of life for them and their family. In addition to offering support to ease symptoms, the palliative care provider also specializes in leading and navigating the goals of care discussion, which we kind of referenced earlier. We help patients consider or even complete their advanced directives as well. Our palliative care providers are serious illness specialists who add another layer of support and work as a part of the patient's medical team. So that's kind of how palliative operates in, in that form or fashion.

KVE: I was going to ask you a lot of times, I know that a patient may start in palliative care and then transition to Hospice is and I know you're going to explain a little bit more about Hospice. Is that a pretty natural transition for a lot of patients?

MH: It is sometimes for patients. We see a lot of patients that truly can be Hospice, but they actually choose palliative because they feel more comfortable still kind of seeking their curative approaches, still seeing their medical doctors still treating their heart failure with the heart failure medications and they really kind of they're just not ready for that Hospice conversation. And but typically I would say palliative and Hospice, we really like to focus on the six months or less for their life span kind of looking at all those factors and then they're just they're truly not ready for Hospice. And so we see more of that palliative care and then our providers will go, will go out visit the patients and then kind of have those goals of care discussions and we identify they're really more appropriate for Hospice at this time. So then we kind of transition them over when they're ready from palliative care to Hospice services.

KVE: How would those services change then once they're on Hospice?

MH: So Hospice, you're going to get more services than with palliative care. With Hospice services, you're going to get that nurse that comes out to do those visits, those weekly visits. You're going to be able to, if elected, have that Hospice aid to come out and help with those ADLs. You're going to get the the Chaplin, the social worker involvement, the bereavement after Hospice after the patient passes away on Hospice services, you're going to get so many more benefits under Hospice than you will with palliative. So that that's going to be a little bit more of the difference with the palliative and the Hospice.

KVE: I appreciate you explaining it that way, because sometimes when I'm telling a patient I think you may need some more services in your home, I'll start the conversation, I'll say palliative, maybe Hospice. That way at least get somebody in the door and I'll say to them, you may qualify for Hospice. Don't think of it as some type of, you know, sentence that says that you're not going to be here in six months, but it's more like more services to support you through this transition. And a lot of times I can get patient and say oh, OK, I think I think I like that way better then.

MH: Absolutely. And if we that's the first step if you can talk the patient into letting us come out having those conversations around the goals of care, that's where it starts at and we can identify the patient's needs based on that conversation. So we can go out, do the assessment, provide the conversation, really kind of dig deep into what the patients short term care goals are. Long term care goals. Have those goals of care conversation with the patient and then explain to them the difference in palliative care and Hospice care. But that goals of care discussion and making sure the patient understands our diagnosis like what their diagnosis truly is. And do they understand the prognosis of their diagnosis? Like what you know, what stage are they at in in heart failure or COPD? Like where are they at and what other treatment options do they have? That could be provided to them. And then the goals of care discussion kind of helps us navigate those conversations that also navigate which way the family and the patient want to move. Is it more palliative right now? We follow them through palliative until they're ready for Hospice or is it truly, once you understand the difference and the benefits that you're going to be provided with Hospice care, is it time to move towards that Hospice care side?

KVE: Do you find that that six-month line in the sand makes some people uncomfortable, whether it's the patient, even the provider, I'm even having trouble saying the words or their family member. And so is that a line in the sand that is a moving target? Does it always have to be 6 months or can that patient have more time in Hospice?

MH: Yes, absolutely. They can have more time in Hospice typically kind of the Medicare guidelines and the Medicare rules would say, you know, if a patient's diagnosis is going to probably progress to where they're only going to be, you know within that six month or less time frame. But we see patients that live longer than six months. And what we see is very interesting because if you bring in Hospice and Hospice gets involved, it improves your quality of life where you know, respecting their wishes, their end-of-life goals and they actually have a better quality of life and they live longer. And there's statistics out there that say if you bring in Hospice and there's they're going to get an extra couple weeks added on to their lifespan because of just the quality of life that we're able to provide them with that extra care.

KVE: That is really interesting. I am definitely going to be telling my patients that, that they actually are going to have a longer lifespan potentially because of the good care that they're getting. That's really important.

MH: Yes, I agree.

KVE: When do you think is the right time to start talking about advanced care planning with a patient? I know you and I are talking about it. We want to come up with a really wonderful robust care model to support this within our value partners. When do you think it's the right time to start it, start talking about it?

MH: That is a great question because I think you're never too young to start thinking about those goals of care. I think, you know, when you're at age, those discussions should be starting to be had per se. I do think it's important. There's not really a certain age limit, but I think it's important when you start, you know your annual Wellness visit that when patients are starting to come in and you know they might, they might even start out with blood pressure or hypertension or hypertension or diabetes. You know it's, it's time to see that they're going to be you know, visiting their providers. We're going to be seeing their providers for that annual Wellness visit. I think it's those conversations should start then they should start very early, you know having those conversations so the patient can understand their wishes because we are not guaranteed tomorrow, no matter how old we are, what age. So I think early on the earlier the better and then especially not that it's too late in the game, but especially when those patients, when you start to see those serious illness patients that have the comorbidities, you know more than one or two comorbidities and they're frequently visiting physician offices. I think that's the time to really there should be like almost a red flag. We need to start having these conversations and talking to the patient about their wishes because we don't want to see them, you know, visit frequently visiting the ED or frequently, you know, inpatient at the hospital having those visits. I think that there's really no perfect timing, but I think the earlier the sooner the better.

KVE: I know that statistics and when they ask patients they want this conversation to be had with their doctor, their primary doctor, that's what they say. A lot of doctors are uncomfortable. Maybe they don't have the proper training on how to even begin the conversation. What in what ways could some an organization like Mountain Valley support providers support institutions, support patients in deciding their how they want to go about their advanced care planning and how they want that to be told to their family members?

MH: Yeah. So I think it kind of starts if I could back up just a little bit, I think it kind of starts on and I'll be happy to share some of the trends that we've seen just recently that I've kind of pulled together. So one of the things that we're seeing at times referral sources, they confuse, they'll confuse palliative care practices with hospice services because it's hard to understand though there's some differences, but there's some similarities. So one of the things that we can offer is palliative care as a private and separate medical practice for patients who are upstream from Hospice services. So that's why we have, those four serious illness clinics. When we see patients, we build a patient's insurance just as any medical specialist would. We can coexist with home services such as home health, physical therapy, etc. When we see patients in their home, which may be why we get sometimes confused with Hospice services. So for patients who prefer to be seen in an office rather than at home, we do have offices in Winston, Salem, King, and Kernersville. We're uniquely independent from Hospice. This is our palliative care serious illness providers. We are easily able to walk the patients through their serious illness journey and help them cross the bridge into Hospice care when that time is right. The patient may remain with our provider team as their Hospice provider once the journey into Hospice services because our provider team practices both Hospice and palliative care. This is welcome news for our patients who have often built a trusting relationship with their provider team. Our ideal palliative care patient referrals are within 6 to 12 months, so a little bit more than that Hospice, that six months conversation we had, but there's 6 to 12 months upstream from Hospice care. In this period of time, we're able to offer support with symptom management. So again, palliative care, symptom management for those symptoms. We have those goals of care in advance directive discussions. Then when the time is right, we support that fluid transition into hostile services. So another trend that we're seeing is that the provider will refer a very sick patient to palliative care when that patient is really advanced enough in their illness, they would benefit more from hostile services and that's what I had kind of talked about earlier when the patients are referred for palliative, but they really should truly be hostile services. We believe this happens at least in part because many providers struggle to mention Hospice or talk about end of life with patients. We understand providers, they get busy. I mean you might have 30-40 patients a day and just to take that time, you know, they're kind of coming in and out and they may not share with you all the issues that they're having and they share with you just some of the issues. But we understand that that's a very difficult conversation to have in doing so is a fine art and must be handled with much dignity, respect and sensitivity. Many times our palliative care providers will see the patient in a first consult and follow a caring and supportive discussion, discover that the patient is ready for hostile services after all and then we can assist with that transition from palliative care to Hospice. So when we get a palliative care referral, sometimes we might go out and do that one visit and by the time we do that education, it's time for them to move over into Hospice care services. The one thing that I would recommend that I think from a provider standpoint and I'm not a provider but just when talking to providers is that you know if you don't have the time to really kind of dig into Hospice or palliative but you have that patient that is red flagging, they have went to the hospital or they're sick or they need that extra care is make that referral. And let us talk about the goals of care because the goals of care is the, I would say that's almost like the golden tool, the golden ticket to kind of understanding what that patient wants. And then you know we have some patients that we have the conversation when they're not really appropriate for Hospice or palliative maybe they need home health services. So we will assess for any of their needs. We have trained providers, trained referral intake coordinators. So you know just I think making identifying the patient needs something and then starting with that goals of care conversation and then you're going to really figure out what it is that patient truly needs by that goals of care.

KVE: When you when you said that last part about, well sometimes they just need home health, I wonder it just sort of made me think, you know, I make a lot of home health referrals. So I how much will home health also bring you in or bring palliative care or Hospice care in once they're in the home and they deem a patient needing those services, Will you get those calls?

MH: We do some, but then again, I don't think we do as much as we possibly could just because when you have home health clinicians, they're not trained in identifying Hospice appropriate patients. They're not trained in those goals of care discussions and we miss a lot of those patients, unfortunately. There's an opportunity there as well.

KVE: Yeah, I can see that absolutely, because there's a lot, probably a lot of patients that would fall through their cracks right there.

MH: Yes, absolutely. There's a lot more education needed.

KVE: if a provider would want to refer a patient to have the discussion about advanced care planning, how would they go about doing that?

MH: So one one thing that I would recommend is that for a provider that doesn't want to have that discussion, just talk to the patient about their goals of care and advanced care planning. And they would like for them to speak to someone who are experts in in having that advanced care planning conversation and this and to make that referral over to Mountain Valley and we can call that patient, reach out, talk to that patient, kind of understand what that patient need, what their needs are and what their goals of care are and we can get kind of getting the ball rolling with that piece.

KVE: When I think about my own practice, I definitely don't see 40 a day. I'm going to just be honest. But I do find that it is there is. There is times when I just. I know I need to have the conversation, the patient wants to talk about something else and I just can't quite get my agenda forward and that would be about talking about advanced care planning. How would you if it was a perfect world and I made a referral, what do you think that would look like? Could advanced care planning be done in a referral process to someone else and it kind of take the provider out of it if they just didn't have time to talk about it?

MH: Absolutely. I do agree that is that could be a practice going forward when you're really busy. And I think it's good to kind of lean on those experts that that have these conversations every day and we kind of that's all we do. It seems like every day, all day which is a great part of our job because we get to help the patient understand do they actually understand what their medical diagnosis is, do they understand what's what impacts it has on their quality of life and then kind of going into what their wishes are during that goals of care discussion. So absolutely. So I think you know just if you see a patient in your practice and you know that they have needs and you don't know what their long term care goals are, short term care goals are, you can make that referral. You can send that referral to us several different ways by fax, by call, by e-mail, by text. And we will have that conversation with that patient. And it's just a matter of picking up the phone calling and sending them resources, meeting with them at one of our serious illness clinics, meeting with them on site and just kind of going through. We have a wonderful booklet. It's called The Five Wishes. And we just walked through that booklet with them kind of understanding what their long term care goals are, what their wishes are throughout this time And it might be they may not even have a diagnosis that would warrant that six months or less, but it kind of gets them kind of pre planning which I think is very important.

KVE: I wondered I'm going to put you on the spot a little Maria. So, you know, I can imagine being a delivery nurse and that's just such, you know, delivering babies is so wonderful and joyful. I can imagine doing all kinds of jobs. I think one of the hardest jobs I can think of is trying to be the support person for a patient who's passing and for their family members. Can you tell me what, where...