Episode 57: Palliative Care Insights from Becca Hutchinson

Heather: This is BACON, brief ACO news from the MaineHealth Accountable Care Organization. A monthly podcast for health care providers. I'm Heather Ward. My co-host Mike Clark is away for the month. Lucky him. But he is missing out. For this episode, I'm joined by Doctor Becca Hutchinson to discuss various aspects of palliative care, including how it can improve the experience of both patients and families, as well as how it can help to reduce the total cost of health care. So, let's get to it.

Heather: This month, I am very pleased to welcome Becca Hutchinson to the show. Becca is a wonderful physician and person, a vocal, energetic senior medical director for the Palliative Care Program at the MaineHealth Medical Group. As you will hear, she is a passionate advocate for palliative care and has led numerous efforts to expand access to palliative care. My patients have personally benefited from her incredible work trying to get us palliative care up here, so we're really appreciative. We are really appreciative of that. Most recently, Becca championed the opening of an innovative outpatient palliative care practice located in Scarborough. So, Becca, I am glad to have you here.

Becca: Thanks a lot, Heather. I'm really glad to be here to.

Heather: Awesome. Okay, so let's start with the basics. I am sure you get this all the time, but what exactly is palliative care?

Becca: Well, it's true, we do get it a lot. And I always take opportunities, even when I'm not asked to define it, because there's still a lot of misconceptions about what we do. But put most simply, palliative care is specialized medical care that treats the symptoms and stress of a serious illness. And really our goal is to improve quality of life. And, you know, I often say to patients when I introduce palliative care that there's a few things that set us apart from traditional medical care. One is that we are interdisciplinary, and our care is provided by a team that often includes physicians, nurses, nurse practitioners, physician assistants, social workers, and chaplains. And it really is to address all of the ways that serious illness impacts people's lives. And then the second thing is that we focus not just on the patient, but also on their support network. So we will actually say to patients, loved ones that we care about them as much as we care about sort of the patient's experience. And that's because we know that for people to do as well as possible with serious illness, we also have to care for the caregivers, because that's a big part of patients doing well.

Heather: I've heard you mention specialty palliative care. Is that the same thing as palliative care, or is there a difference between the two terms?

Becca: Yeah, that's a great question. And um, you know, palliative care itself, the terms really means to cloak. So it really is to kind of put a blanket of support around the patient. And the concept is around sort of making sure that you're providing expert communication and knowledge about the patient's condition as well as managing a patient's symptoms. And we know that clinicians of all specialties are doing that right. You do that every day. It's a primary care doctor and that care that you're providing when you're addressing a patient's symptoms, when you're helping them to understand what's going on and what to expect. That is primary palliative care, right. So we say that's just sort of addressing a patient's palliative care needs, um, as either a primary care doctor or as a disease specialist cardiologist oncologist. Specialty palliative care is care that is provided by clinicians with training in this field. And so that's physicians who are typically go through a fellowship to get this training. And, are board certified in this field. And so, it's sort of that kind of next level for the more complex patient, I would say, is specialty palliative care. And similarly social workers, nurses, etc. have additional training and certification in the field.

Heather: Why do you think there's so much confusion around palliative care? And maybe you could just talk about some of those misconceptions that you had mentioned and just take this opportunity to set us all straight?

Becca: Yeah. I, um, I think I had this experience last week, which was for me, um, both disheartening and also really, uh, a good example of kind of the challenges that we still have as a field in palliative care. I was at a dinner with a couple of other physicians, and I mentioned to an emergency room physician that I had seen one of their patients recently, like, oh, I saw a patient that, um, I noticed you had seen in the emergency room, and the physician's reaction was "really, what?" Like, what did I do wrong that the patient ended up needing palliative care? I was pretty taken aback in that moment. Um, and I said something like, oh, well, you know, palliative care is moved upstream. And there were a bunch of doctors there. And the conversation kind of continued. And and there was some joking around, like the state of medical care today, everyone's going to need palliative care. And I thought, huh, this is a really good example of the challenges we have in getting people to understand sort of what we do. And there's a few misconceptions that are clear in that statement that the emergency room physician said, number one, there's an implication there that palliative care is prognosis dependent, which it is not. Right. So palliative care is exactly, as we said, specialized medical care for people living with serious illness.

Becca: And it can be and is integrated alongside disease directed and sometimes very aggressive care. And so there's nothing about getting or benefiting from palliative care that depends on a patient's particular prognosis. I think the implication there of like I must have done something wrong is conflating palliative care with end-of-life care. And that's really what we, you know, want to differentiate ourselves from is while we are end-of-life care experts, I often think of it as palliative care is kind of an umbrella, an end-of-life care is a very small part of that umbrella, and we do so much more and can benefit patients and families much more if we're involved earlier in the disease trajectory. Um, I think the the other misconception and what the physician was saying is that palliative care is somehow when things go wrong and we know, right, that patients are living with serious illness kind of throughout our health system. Right. Like that's a big part of what we all take care of. It's what I did as a general internist before I did palliative care. And for sure, emergency room physicians are seeing patients with serious illness every day. And we have to get to a place where we are all understanding that palliative care is really a part of high quality medical care.

Becca: And Heather, you said it really well like a couple of minutes ago. Isn't that what we should be doing all of the time? And indeed it is, right, because all of our patients have palliative care needs, and we need to work together as a health system to figure out how to meet those needs through a combination of, um, specialists, I mean, primary care doctors, disease specialists, and then palliative care teams to kind of meet the palliative care needs of all of our patients. Um. And I think, you know, the last thing I'll say about sort of that particular story is that I was, you know, when I was reflecting on it, I was thinking, wow, no one thinks when they're treating a patient with cancer or treating a patient with heart failure. I must have done something wrong to send that patient to an oncologist and need an oncologist, or to need a cardiologist, right? You're actually thinking like, wow, I did the best thing possible. I got that patient to the specialists who know best how to care for their particular medical needs. And that's what we need to how we need to think about specialty palliative care. So these are the experts. These are the teams that can help your patients live as fully as possible with their serious illness diagnoses.

Heather: Yeah. And probably stay out of the ER so that ED physician wouldn't even need to spend their time seeing that patient. Yeah. Wow.

Becca: That's our goal.

Heather: Well I think you know, that sounds like a really fantastic ultimate goal in taking care of our patients just to have your teams there as specialty teams to be that. I mean, it's like a safety net. It's like, you know, security around the patient. It's all the other supports and medical care. And I think it sounds like a fantastic approach. I wanted to shift gears just a little bit. And, you know, we had mentioned earlier that you have been involved in some pretty exciting initiatives in the last couple of years. I wanted to hear a little bit more about the outpatient palliative care practice in Scarborough. I just learned about that, and I really am curious to hear more about it and really kind of how it came to be. What's its story?

Becca: Yeah. And I'll just say from the get go that while I appreciate the credit, I was definitely did not do this alone. As we all know, all of these sorts of things take a ton of teamwork, and in this particular case, took a lot of support from leadership to kind of bring this to fruition. When I started my palliative care journey after being an internist for five years, I at the time at MaineHealth, we really did not have any dedicated space to care for patients in the ambulatory environment. And palliative care was isolated to the inpatient setting. And as increasingly randomized controlled trials have shown the benefit of early palliative care for patients in terms of maximizing their quality of life and decreasing their total cost of care, there has been recognition that palliative care has to move upstream and really into the ambulatory environment. And as you mentioned before, all of our goals are to keep patients out of the hospital and out of the emergency rooms. Right. Um, and so as we were trying to sort of think about this and meet the increasing number of guidelines that exist that, uh, that say specialty palliative care should be involved in, for example, patients with advanced COPD or heart failure or cancer. Um, we realized we needed a space and we couldn't continue to grow in a way where we were constantly trying to borrow, beg, steal someone else's space. And that's sort of what, um, I just started asking over and over again, we need a space. We need a place where the interdisciplinary team can come together and have team meetings. We need a hub where, um, triage nurses can live that can actually help serve patients across the MaineHealth medical group, not just the southern region.

Becca: Um, and we need a space that's, like, truly ours where we can, you know, determine the best use of it and how it works. And also, um, a place where, for example, you know, as we were talking about misconceptions of palliative care for physicians and APPs, there's a ton of misconceptions with patients. And so one of the things you have to get really good at, have patients accept palliative care is you have to have like PSRs and MAs who know how to talk about what palliative care is. Right? So all of that requires sort of staff that's dedicated to palliative care and kind of understands what we do. And so those were all the reasons that we sort of used as justification for a clinic. And thankfully, uh, MaineHealth Medical Group leadership, um, agreed that this was a necessity. And I would say that Aileen and Steve were a huge part of kind of bringing this to fruition, of helping to identify a space and then helping us have the funding to remodel it. And that clinic opened in April of 2023. And at this point, we really see it as sort of the hub for specialty palliative care across the medical group. Um, and as you said, it's incredibly exciting and it's kind of amazing to have a sign that says MaineHealth Palliative Care. And I will tell you that palliative care leaders that I know nationally are very jealous. So it's pretty cool. Yeah.

Heather: That's fantastic. It's interesting that you yo talk about moving palliative care out of the hospital and into the outpatient world because I only know palliative care in the outpatient world based on, you know, my referrals and the, um, lovely care that my patients get in the outpatient world, so they never enter the hospital. Congratulations on getting that. That's really exciting.

Becca: Thanks.

Heather: You mentioned this already a little bit, but it's my understanding that palliative care is s a big area of focus now for the MaineHealth system. I'm wondering if you could talk a little bit about how it might help both reduce unwarranted care variation and also overall cost of care?

Becca: Yeah. And um, so we know that palliative care is associated with decreased costs of care. And here's the tricky thing that those costs of care are especially the the changes, the decrease in costs of care is especially notable at towards the end of life. And so we just spent all this time talking about how palliative care is not just end-of-life care. Um, and, and now I'm going to sort of shift to say that a lot of the decrease in costs really occurred at midlife. And the reason why is a fact that many of us already know, right, that like Medicare expenditures towards the end of life is when they really shoot up. There's a huge amount of money that we spend on patients very close to the end of life. We also know that that care that we're providing is not actually benefiting the patient. It's not improving their quality of life and is not extending their life. And so part of what palliative care is doing in this setting, um, is getting to know the patient and family, making sure that they really understand their diagnoses and what to expect in the future, and putting into context any particular interventions with the likely benefit "Big picture." Right. We really we tell patients all the time, we're the big picture team, right? Instead of talking about how this particular intervention is going to benefit your heart, we're going to talk about what is it going to look like for you to live after this intervention, and is that going to meet what you're really hoping for? And we know that most patients, as they're approaching the end of life, do not want to spend that time in the hospital away from their family.

Becca: Right? They want to spend as much of that time as they can at home, surrounded by the people that they love. And so those conversations ultimately result in patients making different choices. Um, and that goal concordant care means that patients are receiving, you know, having more of their care delivered at home, avoiding hospitalization and avoiding these interventions that are not associated with benefits in either longevity or quality of life. And one thing I didn't say earlier, but I'll take this opportunity to say and emphasize that every randomized, controlled trial that has looked at integration of specialty palliative care early in disease courses has shown that patients live as long or longer with palliative care than they do without. And so again, it just sort of hammers home that these are these interventions that patients are often foregoing when they have access to specialty palliative care, are not those that lengthen their lives.

Heather: Yeah. That's fantastic. So it's so palliative care improves quality of life, potentially lengthens a higher quality of life and does it with cost savings, it sounds like. So that's pretty amazing. You already started to touch on this, but I'm wondering if you could expand a little bit more moving from kind of cost reducing potential to the, um, impact on patients and families? Why does palliative care have such a positive impact on patients?

Becca: Yeah, it's a great question. Honestly. There's a lot of people looking into this in the research of like what's the secret sauce? Because if we could identify that and then maybe it'd be easier to make sure everyone gets it right. Um, and I don't, I don't I honestly don't think that we know. Um, but what we do know, and this is, I think, kind of interesting, too, is that when you ask, uh, physicians and APPS, why don't you refer to specialty palliative care? We often hear, well, I don't want to take away their hope. And we do know, right, that patients after seeing palliative care have decreased rates of anxiety, decreased rates of depression, improvements in their quality of life. And if you look at the data that just like the anecdotal sort of patient responses to our NRC survey, actually multiple patients in the last two months when I was just reading their comments, said talked about how much more hope they had after seeing palliative care. Right. Which is the opposite of what a lot of clinicians think. So, you know, I don't know the answer to exactly what we're doing that's improving quality of life. But I know that that's the most consistent finding in every study that's looked at palliative care. And, um, and then, you know, if you look, for example, at heart failure when they did a randomized controlled trial, specialty palliative care for patients with heart failure, the benefits to quality of life were greater than any medication that you could give your patient.

Heather: Wow. That's pretty impressive. I'm wondering, can you just, like, walk us through what it would be like for a patient to come into your Scarborough practice?

Becca: Yeah. So we have pretty much every patient on their first visit will meet with both a physician, a nurse and a social worker. They'll spend the majority of their time typically with the physician and social worker. We don't have APPs in our clinic yet, but we will over time. So there'll be a part of the care team as well. And, you know, it really kind of the first visit starts out with getting to know the patient. And it's kind of funny because our patients with serious illness are kind of trained. When you say, like, "Tell me about yourself," they'll start telling you about their illnesses and you're like, no, no, I want to know about you as a person. And they're always kind of taken aback. They're like, a doctor wants to know about me as a person. That's weird, but that's a big part. Serious illness is really personal, right? And so what I'm trying to do in that it's not just like I like to get to know people, although I do, but it's really just that understanding sort of how they think. And their experience of illness really helps me to help them navigate sort of the future. So we start with that, just getting to know who they are, how they spend their time, what life has looked like for them, what their experience of illness has been, how they felt about prior hospitalizations, you know, what they've seen in family members being sick, etc. We make sure that the caregiver is sort of fully included in the conversation, right? So pretty much every question we ask the patient, we will then turn to the caregiver and say, anything else you want to add or what are you worried about specifically? So after that we talk about what they understand of their illness, and we do some education around sort of what their conditions are and what we expect for the future.

Becca: Um, and then from there, we talk a lot about values and preferences. What are they hoping for? What are they most worried about? What sorts of things might they want to avoid? And then this is sort of the, to me, the secret sauce of the sort of physician / APP involvement is you take kind of what their medical conditions are, you understand their values and preferences and sort of what makes them tick. And you create a care plan for them that honors their individual values and preferences and takes into account what we know as possible or not possible with medical care. And that's sort of the creation of a care plan. At the same time, kind of throughout that process, you're understanding if they have existential or spiritual stressors that would benefit from being seen by a chaplain. You're assessing their psychosocial issues, and the social workers are both sort of thinking about is, is counseling something that would be helpful, or is this more of sort of needs resource connection? And so they're sort of doing those interventions at the same time. And and then the final piece is symptom management, which we do as well.

Heather: Wow. Thank you. Uh, obviously palliative care has huge potential to help our patients right now. Um, and I'm curious to hear your thoughts on how you see palliative care evolving over the next couple of years.

Becca: Well. I hope. That we will be able to make a dent in the culture change. Um, and really help, uh, not just physicians, APPs, the whole care team, honestly, because nurses can be a huge part of connecting patients with palliative care. But, um, really working on the culture change of clinicians across our health system so that there's an understanding of what we do, and then also working on the education piece for patients and families so that they understand the benefit that would come from, you know, um, engaging with a specialty palliative care team. And practically speaking, the other piece that I think we really are hoping to, um, start and expand on is home based palliative care, because we know a lot of our patients would be better served if we were able to get, you know, resources into the home. So we have a pilot starting in the southern region, um, any day the proforma has been approved, so we need to post positions and hire um, but then we would be starting to see patients in the home in the southern region for Medicare Advantage patients, and then hopefully we'll be able to spread that across the medical group.

Heather: Exciting. That sounds fantastic. Becca, thank you so much for your insights today. And really thank you for the hard work that you've put into improving the lives of our patients and their families. Thank you so much.

Becca: Thanks for having me. It's fun.

Heather: Thanks for listening to BACON this month. You can find all our episodes on our podcast app and at our web page, MaineHealthACO.org/BACON. And if you have questions, comments or suggestions, we would love to hear from you. Please email us at bacon@mainehealth.org. That's Bacon@mainehealth.org. Bacon is produced by the Maine Health Accountable Care Organization. Thanks for joining us. See you next time.