“As our governor has said about palliative care: It’s important that people living with serious illness feel comfortable, whether it be in their home or elsewhere. In Washington, we’re working hard to consider these issues. We have led a major effort through the Bree Collaborative. Their report states: ‘… many patients who would benefit from palliative care do not receive this service. Access issues stemming from lack of workforce, lack of referrals, and lack of a sustainable business model contribute to low utilization rates.’”
– Jason McGill, Assistant Director, Washington Medicaid Programs Division
Patients who need palliative care cannot access the service unless there are sufficient qualified providers to deliver the service. State policymakers can play an important role in creating a palliative care workforce, which includes institutions, physicians, nurses, home health agencies, and others. States have used their full range of policy levers (e.g., legislation, regulation, contracting) to measure the availability of palliative care, establish the qualifications providers must meet to deliver the service, improve palliative care skills among existing providers, and increase the number of specialty palliative care providers in the state.
Palliative Care: A State Resource Guide
Colorado: Establishing Regulatory Standards and Supporting Providers
In 2014, Colorado revised its hospital and facility licensing regulations to include a palliative care definition and standards for facilities providing palliative care. Facilities include nursing facilities, assisted living facilities, and others. The standards require facilities that choose to provide palliative care to have written policies and procedures for its provision. These documents must describe how the facility assesses and supports patients’ needs and goals, provides services and supports, and meets family needs for bereavement counseling. Further, the standards require that facilities document their evaluation of the patient, as well as the services provided to each patient in the patient’s plan of care.
Additionally, the Colorado Department of Public Health and Environment (CDPHE) developed a website to help providers increase their skills. The website hosts eight resources on the topics of having conversations with patients about goals of care and advance care planning. The website also hosts a video by CDPHE on how providers can support patients’ palliative care needs in their practice.
Texas: Using Data to Assess Workforce Needs
In 2015, the Texas Legislature tasked its Palliative Care Interdisciplinary Advisory Council (PCIAC) with assessing the availability of palliative care within the state and making recommendations for improvement to the legislature. By 2016, the PCIAC had established methods and begun to track key palliative care performance measures. The 2022 report to the legislature provides a comprehensive assessment of the availability of specialty palliative care programs within the state and how it has changed over time. It includes palliative care provided both by hospitals and individual certified professionals. It offers both statewide and regional analysis. Data sources include:
- Texas-specific data from the American Hospital Association’s annual survey regarding the provision of palliative care by hospitals with 50 or more beds and 300 or more beds. (The data from this survey needed to be validated by checking hospital websites.)
- Data from the Texas Health Professions Resource Center regarding the number of physicians with a primary or secondary palliative specialty, the number of palliative medicine fellows, the number of certified hospice medical directors, and the number of certified advance practice registered nurses.
- Data from the Hospice and Palliative Nurses Association regarding the number of Hospice and Palliative Credentialing Center certificates for advanced certified hospice and palliative nurses in Texas.
The PCIAC used this information to determine that access to palliative care specialists had improved over time but that it was still below the national average and likely insufficient to meet statewide need. This council was also able to identify that access varied widely among communities and that “within Texas, some communities, such as the Rio Grande Valley, El Paso, and rural areas generally, appear particularly disadvantaged…” This information informed the other aspects of the PCIAC’s work, including annual continuing education events.
In a complementary effort, Texas examined uptake of advance care planning documents by adding two questions to its 2018 Behavioral Risk Factor Surveillance System survey. This allowed the state to collect data on differences in advance care planning uptake by region, gender, ethnicity, and chronic condition, which could be used to identify gaps in uptake and opportunities for increased education.
Tennessee: Webinars for Ongoing Learning and Mentorship to Support New Providers
Tennessee’s State Palliative Care and Quality of Life Advisory Council (Tennessee’s Council) has achieved much since its creation in 2018. The council has created an online directory of palliative care specialty providers and used webinars to provide information to providers (and potential providers) of palliative care. These webinars covered topics such as how to build a palliative care referral practice that other providers will use, how to have difficult conversations with patients, the difference between hospice and palliative care, and advance care directives. Tennessee’s council also partnered with others, including the Tennessee Department of Health and Tennessee Hospital Association, to launch a mentoring program in 2021. The program supported 40 health care providers who were seeking to implement or expand a palliative care program. Mentors, who were current providers of palliative care, worked with each mentee for one hour per month over six months. Finally, the council hosted statewide summits in 2021 and 2022 that sought to expand pediatric and adult palliative care awareness, as well as discuss barriers and solutions to the provision of palliative care.
California: Establishing Standards for MCOs and Providers with Aligned Efforts to Support Implementation
California statute SB 1004 (Chapter 574, Statutes of 2014) required the Department of Health Care Services (DHCS) to establish standards for palliative care and provide technical assistance to managed care organizations (MCOs) contracting with the state Medicaid program (Medi-Cal). The DHCS worked with key actors, such as the Coalition for Compassionate Care of California, to develop the standards. When the new requirements were ready to be implemented in 2018, DHCS provided written guidance to the MCOs in an All-Plan Letter.
The guidance established a minimum set of palliative care services that MCOs were required to make available to beneficiaries who met specified criteria. MCOs could go beyond these minimum expectations with Medi-Cal’s approval. The guidance also required MCOs to use “qualified providers for palliative care based on the setting and needs of a member.” Beyond that, Medi-Cal offered guidance, but did not establish requirements, for the composition of the palliative care team and the qualifications of individual palliative care providers.
DHCS also sought to support palliative care providers in meeting the standards. The agency worked with the California State University Shiley Haynes Institute for Palliative Care to provide access to online palliative care continuing education opportunities for specified Medi-Cal providers.
The California Health Care Foundation (CHCF), in an aligned effort, established a resource center for implementation of the bill and undertook other efforts to support implementation of the standards by MCOs and providers. For example, CHCF, in collaboration with the Coalition for Compassionate Care of California, developed a technical assistance informational webinar series to help palliative care providers implement the standards, with topics that included estimating care delivery cost; volume and eligibility; capacity; quality; and challenges in implementation. In 2021, CHCF distilled MCO and provider experience into a toolkit to help MCOs “assess and optimize a palliative care program that meets or exceeds the state’s requirements.” The toolkit is also meant to be helpful for palliative care providers as they negotiate their relations to the MCOs. This technical assistance was not funded by the state, but state staff did participate in the effort. Taken together, this multi-sector collaboration helped improve the process for the MCOs, the specialty palliative care programs, referring providers, and ultimately beneficiaries.
Georgia, New York, and Vermont: Leveraging Continuing Education Requirements to Build Palliative Care Skills among Non-specialists
Georgia, New York, and Vermont all leverage requirements for continuing medical education (CME) for medical professionals to learn palliative care skills, especially symptom assessment and management.
- Georgia’s legislation requires physicians working in pain management clinics to have 20 hours of CME related to pain management or palliative medicine every two years or be board-certified in pain management or palliative medicine.
- New York’s legislation requires licensed prescribers who have a Drug Enforcement Administration registration number to prescribe controlled substances to complete three hours of coursework on pain management, palliative care, and addiction, within a year of registration and then at least once every three years. Three hours of coursework is hosted online through the University of Buffalo and sponsored by the New York State Department of Health.
- Vermont’s Board of Medical Practice requires physicians completing CME requirements to complete at least one hour of CME on hospice, palliative care, or pain management services.
Resources for Supporting Palliative Care Workforce Improvements
Locating Discipline-Specific CE Requirements by State (Resource, Center to Advance Palliative Care, 2023)
States Make Progress on Palliative Care (Blog Post, NASHP, November 2022)
Perspectives on State Opportunities to Improve Care of the Seriously Ill (Report, Center to Advance Palliative Care, 2022)
Essential Elements of Medi-Cal Palliative Care Services: A Toolkit for Medi-Cal Managed Care Plans and Palliative Care Providers (Toolkit, California Health Care Foundation, August 2021)
Building Infrastructure and Promoting Quality (Report, NASHP, September 2020)
Palliative Care Program Certification (Resource, Center to Advance Palliative Care, June 2020) Provides resource on palliative care certification, including links to organizations that offer certification.
The National Consensus Project’s Clinical Practice Guidelines for Quality Palliative Care (4th edition) (Report, National Coalition for Hospice and Palliative Care, 2018)
Federal definition of palliative care within the Code of Federal Regulations, Title 42 (Federal regulation)
