By: Beth Blevins
An advisory team run by the Washington State Office of Rural Health (WA SORH) is looking at ways to bring palliative care to rural patients through telehealth and better community engagement.
Palliative care aims to relieve the suffering of patients with terminal or life-limiting illnesses. But in rural areas, palliative care isn’t always available locally, especially for patients who don’t immediately qualify for hospice services.
Pat Justis, director of the WA SORH, was drafting ideas for rural palliative care when inspired to start the Palliative Care Rural Health Integration Advisory Team (PC-RHIAT) after hearing a presentation at the 2016 NRHA Annual Meeting. “Seeing there what Stratis Health had accomplished and learned in Minnesota gave me velocity and concrete ideas on how to get this advisory group together,” Justis said.
PC-RHIAT includes a cross-section of perspectives from three domains: palliative care expertise, rural health expertise, and telehealth expertise. “Our role is to be a catalyst—primarily, to do the support to bring the right conversations together, link resources, and give the whole process structure,” Justis said. “We’re laying a framework, and providing tools, coaching, and facilitation for the rural hospitals, clinics, and community team members. The community teams will develop an action plan based in the community and rural community health care organizations. And the teams will decide how quickly they move and how much to take on.”
In addition, Justis affirmed, “we are going to work closely with rural home health and hospice agencies. There’s no way that we’re trying to supplant what they do. What we want is to collaborate and help build complimentary care processes.”
PC-RHIAT also aims to work on sustainable, multi-pronged funding. Justis said that might include grant funding for capacity building, such as helping a Critical Access Hospital or Rural Health Clinic send nursing staff or providers to a national training for palliative care; bringing in case consultation services like Project Echo; and providing paid internship stipends to engage students.
One barrier to funding, however, is that there is no defined Medicare benefit for palliative care, Justis said. “As it stands now, palliative care services under Medicare are covered on a piecemeal basis under the auspices of other types of Medicare-funded services: outpatient care by a physician or non-physician provider, or home health or hospice care if the patient meets the specific eligibility criteria for those programs.”
“So,” she said, “we’re also going to work on payer strategies both within our state and looking at whether we can organize multiple states on an approach to Medicare. We’re hoping to get a national change in policy for funding so palliative care outside hospice is a covered service under Medicare.”
After consensus on the conceptual model, the advisory team will convene its first work group this month. “There are two hospitals that have already done some work, and a few other early adopters,” Justis said. “One of those will move quickly because they’ve laid a lot of groundwork for it already. The pace at which communities take this up will depend on where they are developmentally, and on community engagement and how many resources they have for it.”
The overall goal, Justis said, is to have a model where the work groups are the instigators and tool providers. “(The advisory team) wants to gradually hand off the heart of the work to the community teams as we put our focus on policy change.”
According to Justis, the advisory team is currently being funded with in-kind contributions. “The new SORH budget has a small amount committed,” Justis said. “We have a grant writing plan and strategies to work with payers. And a small amount of Flex funding has helped CAH staff with travel costs, although most meetings, but not all, are done via Zoom.”
The advisory team is bringing to fruition Justis’ long-time interest in palliative care. “I began working with hospice as a concept as an undergrad and did internships around it in graduate school,” she said. “It has long been a desire of mine to look at ways for people to stay in their community without being sent away for treatment that might not be what they need or want.”
Justis added, “The conversation should be about quality of life. ‘How can we get you more comfortable? What are your goals? How can we support those?’ That’s true for patients and family. That’s what I love about palliative care and hospice—the goals of patients and family are at the center of what happens.”
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Director, Washington State Office of Rural Health
How did you get to where you are now?
I have a Master’s in Counseling Psychology and got into healthcare on an inpatient psychiatric unit where I worked for 14 years. The hospital was doing Total Quality Management and I ended up working another eight years in quality improvement at a semi-tertiary center that served five rural counties. I tried my own business for a few years doing consulting, writing and photography. I’ve now been with the Washington State Department of Health (DOH) since 2009 and in my current position for two years. In my first six years at the DOH, I ran statewide and regional PCMH collaboratives. The last one was in a rural area, which got me very hooked!
What is the most important thing you are working on right now?
We are getting ready to launch a palliative care integration project with the idea that no rural community can stand up a free-standing palliative care service. We’re working on a Project ECHO type service of case consultation and exploring the feasibility of using board certified palliative care to provide direct patient telemedicine to rural communities. We want to create rural Centers of Excellence and integrate a training and technical assistance package to clinical teams to help with the culture change and how to think differently about this aspect of care. The overall goal is to minimize the use of long-term care beds and decrease transfers to tertiary centers for people who are not going to get better. We want to help people stay in their communities for care so they have the support of loved ones, which everybody needs when they are vulnerable and sick. We also consider site visiting as one of the most important things we do. Rural constituents would say we are visible and attentive and that we show we care by going to them.
What are some great things about rural health in your state?
We are a super diverse state with strong leadership and a lot of wonderful supports out there. We have only had one CAH closure. The University of Washington Research Center is near to us and we get a lot of interaction with the researchers. We also have strong partnerships with the Hospital Association and the Washington Resources Group, which is made up of the DOH, our Primary Care Association and both AHECs. We meet and lay out a calendar of residency visitations and canvas every residency across the state.
You recently hired new staff. What skill sets do SORH staff need?
I look for a sense of passion and empathy for rural communities. I look for staff who get along with others and are resilient when faced with a challenge. Instead of saying something’s too big and we can never get it done, what can we say “yes” to? We are a relatively new team, which gives us the ability to see things in a new way and make changes thoughtfully and with respect for how things have been done. We can step away from “we’ve always done it this way” and really try some new things. They are all very dedicated professionals.