Two years ago, I transitioned from a leadership role at a home delivery pharmacy to a new role as CEO of a pharmacy benefits manager (PBM) focused on the needs of hospice providers. Coming from the same family of industries, I already knew quite a bit about the business, but as I learned its inner workings, what surprised me most was just how unique the hospice model is within the larger health care system.
What stands out most about hospice care is its singular focus on the patient experience. The goal is to treat the whole person through both symptom management and social/spiritual support. This mindset extends to the needs of family caregivers, and—as anyone who has helped navigate care for a loved one can attest—it’s an area that innovators across the care continuum can learn from.
Medication & Pain Management
There is often a sense of immediacy in hospice care. Patients with advanced disease may experience new or worsening symptoms quickly and without warning. When that occurs, the hospice nurse must coordinate medication changes promptly, sometimes within a few hours—nurses and pharmacists are important members of the patient interdisciplinary team, a similar dynamic to that found in long-term care settings and with care in the home.
Hospice pharmacology also has very different best practices compared to other areas of health care, particularly around pain management. Patients experiencing life-limiting conditions present special challenges due to functional and metabolic changes. This creates a unique dynamic in nurse-pharmacist consultations. Conversations are collaborative, concise and highly focused, with the pharmacist making detailed recommendations based on a patient’s symptoms, comorbidities, other medications and goals of care.
The hospice pharmacist’s recommendations may include a new medication to treat an emerging symptom and also may involve discontinuing drugs that are no longer helpful and that might cause undesirable side effects or interactions. Patients often come into hospice care using seven or more medications prescribed over the years by multiple clinicians; sometimes they take drugs to control the side effects of previous prescriptions. The hospice pharmacist can help simplify and optimize the patient’s medication regimen for greater comfort and safety.
The Client Experience
Although the hospice PBM is retained by hospice leadership and ultimately responsible for ensuring medication access for patients, most of our day-to-day interactions are with nurses who, particularly in home settings, are the primary professionals providing direct care, instructing family caregivers on treatment and coordinating with prescribers. Our customer experience is largely the nurse experience. This requires a different mindset from any consumer or business-to-business audience I’ve served in the past. Hospice nurses are highly mission-driven and fierce advocates for their patients.
That sense of mission tends to extend to all of us who serve and work closely with the hospice community. Our own Enclara employees, for example, are personally driven to help make nurses’ lives easier by freeing up their time so they can focus on patient care. To help put that into practice, we employ a number of successful tools—from nurse surveys and focus groups to journey mapping—that help us understand how we can best design our operations, workflows, educational materials and digital tools to help improve nurse efficiency. It also takes a certain level of empathy for these everyday heroes whose work, while often incredibly rewarding, inevitably exacts an emotional toll as well.
I have come to appreciate strengths in the hospice model that can help inform innovations in both acute and chronic illness management. Current demonstrations around value-based insurance design (VBID) are already providing new opportunities for hospice and managed care organizations to both form and strengthen collaborations, and it is my hope that health care professionals will adopt some of the same care delivery and patient/caregiver experiences that are common among hospice providers.