The Value of Palliative Care’s Interdisciplinary Approach

At a broad level, palliative care is focused on patient-centered care: it is about all the dimensions that are required to make sure that a patient is well, from a physical to psychosocial aspect. In pursuit of those goals, a comprehensive palliative care program benefits from the input of an interdisciplinary team that can provide the support and resources patients need to manage their challenges.  

While this is the ideal, it is not standard or available across all programs, as reimbursement structures vary. This article examines the relationship between interdisciplinary care, high-quality palliative care and improved outcomes, and explores why including this approach has value. 

The primary goals of palliative care 

According to the National Hospice and Palliative Care Organization (NHPCO), “Palliative care is patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering.” ¹ This care is not only for the end of life— palliative care can be initiated at any time, starting with the diagnosis of a chronic or complex illness, regardless of whether the patient seeks curative treatment.  

This makes palliative care ideal for ongoing health concerns — allowing patients and their families to gain a better understanding of their treatment options and the potential course of their illness, so they are not making difficult decisions too late. If initiated early, palliative care provides an opportunity for the time and space needed for advance care planning and hospice discussions well ahead of needing end-of-life care. 

A strong palliative care program helps with care navigation, addressing not just physical symptoms but also social service needs and gaps in care coordination, helping patients cut through the sometimes-confusing tangle of phone calls, appointments, specialists and decisions that must be made on their healthcare journey. 

A team approach to delivering palliative care 

As at-home palliative care has continued to grow in the past few years, organizations such as the Center to Advance Palliative Care (CAPC) have suggested guidelines to standardize the quality of care delivered. In their recommendations, CAPC has included the interdisciplinary team, and suggests that the following criteria be met: ² 

• The team should be represented by at least three of the following disciplines: physician, nurse practitioner, nursing (RN or LPN), clinical social worker or spiritual care professional 

• At least one prescribing provider should have specialty palliative care certification  

Including an interdisciplinary team approach in palliative care helps support how the care is delivered and how its primary goals are met. When a palliative care program is without team members like a social worker or nurse practitioner to address a patient’s varied challenges, it becomes harder to help them find solutions to their problems, diminishing the essential role of palliative care and forcing care back to acute care facilities.  

At Contessa, our interdisciplinary team includes a physician, nurses, nurse practitioners, social workers and clinical managers. Much of what the interdisciplinary team does is behind the scenes, communicating with patients, families and their larger healthcare team to make sure goals are aligned.  

For example, when a patient goes home from the hospital, did someone have a conversation with the primary caregivers ahead of time to make sure everyone understands what’s needed? When the field team is in the home, they can further ensure the patient and family are connected with resources for any needs that are discovered, preventing delays in care and decreasing the risk of readmission to the hospital. This level of support is strengthened by relationship-building through care consistency with personalized treatment plans tailored to the patient’s unique healthcare needs.  

In this model, the team works seamlessly to coordinate all needed care. While performing an initial in-home visit, the nurse is able to determine the patient’s needs related to safety, activities of daily living, medications, availability of caregivers and more. The nurse practitioner then connects with the patient virtually and offers support for advance care planning and other needs. The social worker supports the entire team, evaluating community resources for aid like food supplies, medication cost programs, caregiver support services and resources to reduce transportation barriers. These are all areas that can predict a patient’s risk for readmission and, unaddressed, may decrease quality of life for patients and their families.  

If a patient needs medication refills, that can be addressed. If they do not have a primary care doctor, the team can help them find one. Is caregiver support a challenge? The social worker can support them in applying for assistance. 

Decreasing unnecessary care 

This “all-hands-on-deck” approach has the effect of reducing unnecessary care. Research indicates that patients receiving at-home palliative care delivered by an interdisciplinary team are less likely to be admitted to the hospital or to visit the emergency room, for example. ³  

The palliative care interdisciplinary team is skilled in finding practical solutions for improving quality of life while also helping patients and their families understand any realistic limitations. Outside of palliative care support, we might see a heart failure patient be referred for costly physical therapy by their primary care provider due to mobility issues; a palliative care team can step into this scenario and work to relieve symptoms with targeted, evidence-based interventions while educating the family about the progression of the disease so they know it is expected that endurance will decrease over time. They can also discuss when a transition to hospice would be most appropriate, vs. returning to the hospital to fix a problem that cannot be fixed. 

Services that are ordered as part of palliative care, such as home health, are carefully monitored to ensure they are only lasting as long as the patient is benefiting from it. As care needs evolve, adaptations are made along the way to meet their goals of care, supported by appropriate members of the interdisciplinary team. The idea is to never use testing and services in place of a good goals-of-care conversation. The patient should always be provided with the knowledge needed to understand the severity of the disease and their current health status to make good, informed decisions.  

A benefit for all with palliative care in the home 

Across the care continuum, providers, health systems, payers and patients are beginning to see the benefits of a healthcare system that includes community-based palliative care teams as a standard offering. In response, more organizations are investing in palliative care, fueling its continued growth. ⁴ 

Our Palliative Care at Home program continues to provide interdisciplinary care via its value-based offering, with a resulting patient satisfaction rate of 90% and almost 90% of patients having documented advance care planning within 60 days of admission. It is this level of quality that will continue to drive successful palliative care delivery, benefiting patients, families and providers alike.  

By ensuring that a patient’s journey through a complex or chronic illness is guided by a strong palliative care program and interdisciplinary team, we can help meet their goals of care and improve quality of life at home— changing the face of healthcare.