Primary Palliative Care

Primary Palliative Care

Primary care practice is rapidly evolving in response to emerging legislation and calls from national stakeholders to integrate palliative care into mainstream primary care. Recent California Senate Bill SB 1004 requires the California Department of Health Care Services (DHCS) to “establish standards and provide technical assistance for Medi-Cal managed care plans to ensure delivery of palliative care services.”  Additionally, there has been a nearly universal call for educating primary care physicians (PCPs) in palliative care principles.

Core Components Define Primary Palliative Care

Primary palliative care includes the following core components:

• An interdisciplinary team approach that focuses on the patient and family. Primary care physicians (PCPs) should, as needed, elicit assistance from nurses, social workers, chaplains, and home health aides to meet the palliative care needs of their patients. A team approach is needed for two reasons:
  • First, providers of multiple disciplines are needed to address the physical, emotional, spiritual, and social care needs of palliative care patients.
  • Second, PCPs increasingly are being overworked as a result of health care reforms that have shifted all types of care away from specialists and toward frontline providers. Consequently, to be sustainable, a primary palliative care workforce must comprise not only PCPs but other supportive care providers as well.
• Palliative care provision that is concurrent with the patient’s usual care, including curative care.
• Ongoing care management, coordinated by the primary care physician, to fill gaps in care and ensure that the patient’s medical, social, and spiritual needs are being met.
• Advanced care planning that empowers patients and their families to make informed decisions and choices about end-of-life care.
• Facilitated transition to hospice as appropriate.

Evidence of Effectiveness

One of the most widely advocated palliative care interventions entails training  primary care providers in palliative care.  This approach is responsive to recommendations in the Institute of Medicine report on “Dying in America,” which calls for “all clinicians…who care for people with advanced serious illness (to) be competent in basic palliative care (2015, p.4 of Key Findings and Recommendations).”  Insurance and health care providers echo this recommendation, with reports that primary care practice is rapidly evolving in response to current calls from national stakeholders and professional groups to integrate palliative care into mainstream primary care.  The key to change, they say, is clinician training.

Evidence to support palliative care training for primary care physicians (PCPs) is growing. A recent meta-analysis found that PCP training in palliative care resulted in improved opioid prescribing, increased knowledge of palliative care processes, and greater caregiver satisfaction. Other studies have found that palliative care training for PCPs is associated with improved palliative care knowledge, PCP confidence in providing pain and symptom relief, advance care planning rates, and self-reported palliative care practice, as well as decreases in patient symptoms and family anxiety.

The Bottom Line