Content uploaded by Donna Lake
Author content
All content in this area was uploaded by Donna Lake on Feb 15, 2021
Content may be subject to copyright.
INVITED COMMENTARY
249
NCMJ vol. 81, no. 4
ncmedicaljournal.com
As the population ages, the number of people living with
serious illness is increasing and the demand for quality,
timely, person-centered palliative care is growing. We need
specialized, trained health professionals working in collab-
orative teams to answer this call. It is upon health care lead-
ers and policymakers to jointly design, build, and sustain
a workforce to ensure all North Carolinians have access to
care during a serious illness or end of life.
As an educator, researcher, health care leader, nurse,
member of the North Carolina Institute of Medicine’s
Task Force on Serious Illness Care, and caretaker over the
last 10 years, I have observed North Carolina’s response to
the growing care demands of individuals with serious illness
and their families. As a caretaker of my 84-year-old mother,
over the years I have experienced the personal challenges of
the serious illness journey as we have navigated the maze of
finding the right health care team, facilities for serious illness
hospitalizations, home health, hospice, assisted living, and
now home care during a pandemic. These experiences have
provided a laboratory for understanding the reality of seri-
ous illness care within our state. One thing that is constantly
clear: individuals with serious illness need timely access to
quality care provided by an interprofessional collaborative
team.
This commentary is a call to action for North Carolina to
grow its specialty palliative care and hospice workforce by:
1) developing and enhancing palliative and hospice inter-
professional collaborative care teams through purposeful
designs of proofs of concept in various transitional models
of care (e.g., acute care, community, hospice); 2) recruiting
and building a sustainable palliative specialist workforce that
can lead, train, and prepare interprofessional collaborative
team practices to enhance engagement with serious illness
patients and families to meet their goals of care; and 3) pur-
suing legislative and grant funding for the development of a
sustainable serious illness workforce and further research
on the evaluation of serious illness workforce capacity and
impacts.
Team Science and Health Systems Science
As a scientist, I subscribe to the “science of team science”
(SciTS) methodological strategy aimed at understanding
and enhancing the processes and outcomes of collabora-
tive, team-based research. SciTS seeks to shed light on what
makes effective teams produce the best outcomes [1]. The
Institute for Healthcare Improvement Triple Aim Initiative
goals of improved patient experience, improved care for
patient populations, and decreased cost utilize teams to
create change within our health systems [2, 3]. In addition,
applying the creativity of new science to building stronger
academic and clinical partnerships within pallative care
delivery can assist in creating new care models. For exam-
ple, the American Medical Association in 2013 recognized
a gap in medical school education and initiated a change
process that involved recruiting innovative thinkers through
the Change in Medical Education Consortium; as part of that
work, the East Carolina University Brody School of Medicine
(BSOM) was selected as the first of 11 schools to develop a
Redesigning Education to Accelerate Change in Healthcare
(REACH) team. As a member of this process, I witnessed
the powerful impact of a curriculum redesign that incorpo-
rated quality improvement principles, tools, and interprofes-
sional collaborative teams [4-6]. This work also culminated
in the national development of Health Systems Science,
which is the fundamental understanding of how health care
is delivered, how health care professionals work together to
deliver that care (team science), and how health systems
can improve health (quality principles with interprofessional
collaborative teams) [7].
Although SciTS and Health Systems Science are new and
still undergoing evaluation and further study, they are only
A Call for North Carolina to Surround
the Seriously Ill and Caregivers with
Interprofessional Collaborative Teams
Donna Lake
Electronically published July 6, 2020.
Address correspondence to Donna Lake, 106 Cassedale Dr, Goldsboro,
NC 27534 (laked@ecu.edu).
N C Med J. 2020;81(4):249-253. ©2020 by the North Carolina Institute
of Medicine and The Duke Endowment. All rights reserved.
0029-2559/2020/81408
NCMJ vol. 81, no. 4
ncmedicaljournal.com
250
the beginning of a movement toward acquiring new thinking
to improve care delivery.
Workforce Demand
As the palliative care workforce grows, especially in
oncology and geriatrics [8] and in pediatrics [9], there is
evidence that interprofessional collaborative teams are
also growing and showing improved quality of care and
cost savings [9-12]. Most studies have shown that palliative
care reduces the cost of health care by $1,285–$20,719 for
inpatient care, $1,000–$5,198 for outpatient and inpatient
combined, $4,258 for home-based, and $117–$400 per day
for home/hospice combined outpatient/inpatient palliative
care [12]. Across the United States, the National Palliative
Care Registry recorded 1,404 palliative care teams across
1,905 care settings and 2.6 million initial patient consultants
in 2020 [13]. The National Palliative Care Registry Seminar
reported in 2008 that 41% of participating programs had
a full, core interprofessional team of physician, advanced
practice nurse (APRN - typically a nurse practitioner), reg-
istered nurse, social worker, and chaplain, with a 150%
increase in full-time-equivalent APRNs since 2008 [14]. The
registry also found a reported increase of 54 pediatric pal-
liative programs in teaching hospital academic centers and
medium 200-bed facilities [14].
From a population health perspective, North Carolina is
the ninth most populous state, with 10.49 million residents
[15]. North Carolina also has a high prevalence of economic
distress, with 40% of all counties ranked as Tier One, being
the most distressed based on average unemployment,
household income, adjusted property tax per capita, and
population growth [16]. In addition to health professional
workforce challenges to include physicians, nurses, social
workers, and mental health providers, key issues confront-
ing health care in North Carolina include the rising cost of
coverage, gaps in coverage, increased chronic conditions, an
aging population, and limited access to care facing most of
our rural populations.
The North Carolina Institute of Medicine’s Task Force on
Serious Illness Care recognized the critical importance of
developing a system and culture that aims to improve the
quality of living for individuals with serious illness, their
families, and their communities. Among all adults aged 65
and over, it is estimated that around half will develop an
illness serious enough to need long-term care or services,
and about one in seven will need service for longer than five
years [17].
Workforce Challenges
A recent study by the Center to Advance Palliative Care
found that two-thirds of community palliative care programs
are operated by hospitals or hospice care facilities, with the
remainder operated by home health agencies, long-term
care facilities, and office practices or clinics [18]. Only 6%
of programs serve children only, and less than one-quarter
(24%) treat children in addition to adults [18].
Recent national estimates show the nation has 4,400
hospice and palliative medicine specialists, the equivalent of
1 for every 20,000 older adults with serious illness [19]. In
order to meet the growing need for specialty palliative care,
an additional 6,000-10,000 specialty palliative care physi-
cians and an equal number of advanced practice nurses
would be needed (email communication, Julie Spero, MSPH,
director of the North Carolina Health Professions Data
System, UNC, February 26, 2020). In addition, only 25%
of national hospital-based palliative care programs meet
staffing recommendations (include at least one physician,
one advanced practice nurse or registered nurse, one social
worker, and one chaplain) [19]. In community palliative care
services, training, demand, and turnover were cited as work-
force-related barriers to access [19].
In North Carolina, there are a reported 221 active,
licensed physicians in practice who were board certified in
Hospice and Palliative Medicine [20]. Palliative care has
grown significantly over the past two decades—less than
25% of hospitals had a palliative care program in 2000 [21],
and 93.7% of hospitals with more than 300 beds had a pal-
liative care team in 2019 [22]. Despite the growth of the
field, access to palliative care varies widely and many com-
munities lack access, particularly in rural areas where health
care access remains challenging across types of care. For
example, in 2019 there were 62 counties in North Carolina
without a physician that specialized in palliative medicine
[23]. Overall, hospital palliative care is most common in
urban communities.
North Carolina is experiencing workforce shortages in
pallative and hospice care. These shortages limit access to
care and are expected to increase over the coming decades
due to provider burnout, an aging workforce, low wages,
and an inadequate workforce pipeline [24]. The bulk of day-
to-day care is provided by frontline staff, and the median
pay for home health aides in 2018 was $11.57 per hour, or
$24,060 per year [25]. In 2019, there was an 82% turn-
over rate among home care workers [26]. Over the next
two decades, the number of patients eligible for palliative
care is expected to grow by 20%, while the physician work-
force grows by only 1% [20]. Nurses are critical providers of
palliative care and interact with those who are seriously ill
and their families more than any other sector of the work-
force [27]. While there is not an overall shortage of nurses
in North Carolina, there is disparate distribution of nurses
within the state, such as in rural counties [28].
These challenges ring a clear sense of urgency for
patients and their families, policymakers and legislators,
and health professionals to reprioritize our commitment to
improving pallative care and hospice care.
Interprofessional Collaborative Team-based Care
Interprofessional collaboration in health care, defined as
workers from different professional backgrounds working
251
NCMJ vol. 81, no. 4
ncmedicaljournal.com
together with patients, families, caregivers, and communi-
ties, dates back to 1972, with the Institute of Medicine call-
ing for team-based patient care as a way to improve patient
outcomes and safety. In 2009, the United States formed the
Interprofessional Education Collaborative (IPEC), involving
over 20 health professional education associations. For over
10 years, students have been learning how to work together
for improved patient care and health outcomes in schools of
medical, nursing, pharmacy, and physical therapy, however,
this has been a slower process in practice [29].
Interprofessional collaboration supports person-cen-
tered care and takes place through teamwork; it is more
than sharing data and efficient communication between
nurses and physicians. It requires team members to engage
with the patient and with each other, a process that relies on
trust, respect, and understanding of each other’s role in the
care of the patient and family. Interprofessional collabora-
tion in health care requires culture change [30].
A growing body of literature has produced models for
interprofessional collaborative practice and identified core
competencies. In the 2016 release of the Core Competencies
for Interprofessional Collaborative Practice, the IPEC Board
updated its original 2011 document to reflect the focal areas
of 1) values and ethics, 2) roles and responsibilities, 3) inter-
professional communication, and 4) teams and teamwork
[29]. In North Carolina, Four Seasons Compassion for Life, a
state leader in serious illness care, uses an interprofessional
collaborative practice model to develop competency in care
teams across these focal areas (Figure 1). Primary elements
of the model include continuous assessment of team per-
formance and learning, training on team-based care, and
relationship building across team members. This model also
demonstrates how the team can deliver goal-concordant,
coordinated, collaborative interprofessional team care for
individuals with serious illness via competent communi-
cation skills and teamwork with physicians, nurses, social
workers, chaplains, and volunteers. Of particular impor-
tance in collaborative team-based care for individuals with
serious illness is the recognition of the individual and their
family as integral members of the care team.
figure 1.
Interprofessional Collaborative Practice Model
The Four Seasons Interprofessional Collaborative Practice (IPCP) model in end-of-life care guides the development of
IPCP competency in four domains: roles and responsibilities of each team member, communication, collaboration, and
values and ethics.
Source. Four Seasons Compassion for Life. Reprinted with permission from http://www.ncmedicaljournal.com/content/79/4/256.full.pdf.
NCMJ vol. 81, no. 4
ncmedicaljournal.com
252
Strategies for Building a Stronger Health
Professional Workforce
There is evidence indicating an improvement in outcomes
for patients, caregivers, and health systems in the area of
serious illness care when specialty palliative care teams are
integrated. Based on the literature, palliative care may occur
at the time of diagnosis and throughout the course of a seri-
ous illness. The palliative care field has experienced growth
in the following areas: consultation teams, outpatient clin-
ics, community-based models, and medical specialty soci-
eties that recommend specialty palliative care involvement.
However, the data also shows significant stressors in lack of
specialty providers and overwhelming patient demand.
There is a need for data regarding workforce size, training
pipeline, training needs, and care delivery. Early data from
an innovative research team at the Duke Cancer Institute
suggests the average annual growth of palliative care fellow-
ship programs in 2009-2018 (25 fellowship positions per
year) will continue through 2028, with an average sustain-
able number of 575 fellowships per year [31]. The research-
ers determined an average patient load by analyzing the
patient-to-physician service ratio based on Medicare enroll-
ees set to receive palliative care, and projected a future aver-
age of 23 seriously-ill-to-critical patient visits per day [31].
The researchers stated the gaps will make palliative care
unsustainable over time, arguing that there exists no tenable
way forward without the increased use of interprofessional
palliative care team members in the assessment and man-
agement of seriously ill patients [31].
There is also a need for legislative policies at the national
and state levels to enhance health professional workforce
numbers. For example, US House Bill 647, the Palliative
Care and Hospice Education and Training Act, addresses the
adequacy and sustainability of the specialty palliative care
workforce and interprofessional team-based funding [32].
As of this writing, the bill has passed the House and is await-
ing approval in the Senate. If this legislation passes, it will
fund 50 physicians in the first five years and 183 interpro-
fessional trainees through palliative care academic career
development awards, as well as funding training centers and
short-term intensive training programs to build clinical skills
in caring for people with serious illness. This would meet a
significant need, as there are currently only six palliative care
fellowship positions for advanced practice registered nurses,
with three more in the planning stages; six graduate schools
of nursing have palliative care as an additional subspecialty
focus, and eight programs offer masters degrees or certifi-
cations in palliative care (personal communication, pallia-
tive care specialist Connie Dahlin, director of Professional
Practice, Hospice & Palliative Nurses Association).
The current education and training programs for cer-
tified palliative care team members are not sufficient to
meet growing needs. Evidence shows that many practic-
ing health care professionals report a lack of education in
the knowledge and skills needed to practice palliative care
[31]. Therefore, there is a need for a champion leader to
create an innovative statewide planning team to provide
legislative proposals and funding for specialty training for
the serious illness workforce during this time of increased
demand for this specialty [32]. North Carolinians deserve
timely, accessible health care during a serious illness or end
of life, and this is a proposal to consider in moving us for-
ward together.
Donna Lake, PhD, RN, FAAN professor, Advanced Nursing Practice
and Education, College of Nursing, East Carolina University, Greenville,
North Carolina.
Acknowledgments
Potential conflicts of interest. D.L. reports no relevant conflicts of
interest.
References
1. Baker B. The science of team science: an emerging field delves
into the complexities of effective collaboration. BioScience.
2015;65(7):639–644. https://doi.org/10.1093/biosci/biv077
2. Stiefel M, Nolan K. A Guide to Measuring the Triple Aim: Population
Health, Experience of Care, and Per Capita Cost. Boston, MA: Insti-
tute for Healthcare Improvement; 2012.
3. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health,
and cost. Health Aff (Millwood). 2008;27(3):759-769. doi: 10.1377/
hlthaff.27.3.759
4. Lawson L, Lake D, Lazorick S, Reeder T, Garris J, Baxley EG. Develop-
ing tomorrow’s leaders: a medical student distinction track in health
system transformation and leadership. Acad Med. 2019;94(3):358-
363. doi: 10.1097/ACM.0000000000002509
5. Walsh DS, Lazorick S, Lawson L, et al. The Teachers of Quality Acad-
emy: evaluation of the effectiveness and impact of a health systems
science training program. Am J Med Qual. 2019;34(1):36-44. doi:
10.1177/1062860618778124
6. Baxley EG, Lawson L, Garrison HG, et al. The Teachers of Quality
Academy: a learning community approach to preparing faculty to
teach health systems science. Acad Med. 2016;91(12):1655-1660.
doi: 10/1097/ACM.0000000000001262
7. Higginson J, Lake D. Principles of Teamwork & Team Science. In:
Skochelak SE, ed. AMA Education Consortium: Health Systems Sci-
ence. 1st ed. Chicago, IL: Elsevier; 2016:81-91.
8. Morrison RS. Models of palliative care delivery in the United States.
Curr Opin Support Palliat Care. 2013;7(2):201–206. doi: 10.1097/
SPC.0b013e32836103e5
9. Hughes MT, Smith TJ. The growth of palliative care in the United
States. Annu Rev Public Health. 2014;35:459-475. doi: 10.1146/an-
nurev-publhealth-032013-182406
10. Ahluwalia SC, Chen C, Raasen L, et al. A systematic review in sup-
port of the National Consensus Program Clinical Practice Guidelines
for Quality Palliative Care, Fourth Edition. J Pain Symptom Manage.
2018;56(6):831-870. doi: 10.1016/j.jpainsymman.2018.09.008
11. Cassel JB, Bowman B, Rogers M, Spragens LH, Meier DE, Palliative
Care Leadership Centers. Palliative care leadership centers are key
to the diffusion of palliative care innovation. Health Aff (Millwood).
2018;37(2):231-239. doi: 10.1377/hlthaff.2017.1122
12. Yadav S, Heller IW, Schaefer N, et al. The health care cost of pal-
liative care for cancer patients: a systematic review. Support Care
Cancer. 2020. doi: 10.1007/s00520-020-05512-y
13. National Palliative Care Registry website. https://registry.capc.org/.
Accessed June 18, 2020.
14. Rogers M, Heitner R. Latest Trends and Insights from the National
Palliative Care Registry. Center to Advance Palliative Care website.
https://www.capc.org/events/recorded-webinars/latest-trends-
and-insights-from-the-national-palliative-care-registry/. Published
August 13, 2019. Accessed Jun 18, 2020.
15. United States Census Bureau. QuickFacts: North Carolina. United
States Census Bureau website. https://www.census.gov/quick-
facts/NC. Accessed February 25, 2020.
253
NCMJ vol. 81, no. 4
ncmedicaljournal.com
16. North Carolina Department of Commerce. 2019 North Carolina
Development Tier Designations. Raleigh, NC: North Carolina De-
partment of Commerce; 2019. https://files.nc.gov/nccommerce/
documents/files/2019-Tiers-memo_asPublished.pdf. Accessed Jun
18, 2020.
17. North Carolina Institute of Medicine. Improving Serious Illness
Care in North Carolina. Chapter 1: Introduction And Overview.
Morrisville, NC: NCIOM; 2020. http://nciom.org/wp-content/
uploads/2020/06/NCIOM_Improving-Serious-Illness-Care-in-
North-Carolina_Full-Report_April-2020.pdf. Accessed April 15,
2020.
18. Haitner R, Rogers M, Meier DE. Mapping Community Palliative Care:
A Snapshot. Center to Advance Palliative Care website. https://
www.capc.org/documents/700/. Published December 16, 2019.
Accessed June 15, 2020.
19. National Palliative Care Registry. Research in the Field: Staffing and
Workforce. National Palliative Care Registry website. https://regis-
try.capc.org/metrics-resources/research-in-the-field/. Accessed
June 19, 2020.
20. North Carolina Institute of Medicine. Improving Serious Illness
Care in North Carolina. Chapter 5: Development of the Health and
Human Services Workforce and Infrastructure to Improve Serious
Illness Care. Morrisville, NC: NCIOM; 2020. http://nciom.org/
wp-content/uploads/2020/06/Chapter-5.pdf. Accessed April 15,
2020.
21. Palliative Care Growth Trend Continues, According to Latest Center
to Advance Palliative Care Analysis [press release]. New York, NY:
Center to Advance Palliative Care; September 2, 2014. https://www.
capc.org/about/press-media/press-releases/2014-9-2/palliative-
care-growth-trend-continues-according-latest-center-advance-
palliative-care-analysis/. Accessed January 30, 2020.
22. Center to Advance Palliative Care, National Palliative Care Research
Center. America’s Care of Serious Illness: A State-by-State Report
Card on Access to Palliative Care in Our Nation’s Hospitals. New
York, NY: Center to Advance Palliative Care; 2019. https://report-
card.capc.org/wp-content/uploads/2019/09/CAPC_Report-
Card19-Digital_9_19.pdf. Accessed January 30, 2020
23. Data query: Physicians, Hospice and Palliative Medicine. The Ce-
cil G. Sheps Center for Health Services Research. North Carolina
Health Professional Supply Data. NC Health Workforce website.
https://nchealthworkforce.unc.edu/supply/. Published 2020. Ac-
cessed February 5, 2020.
24. Harrison KL, Dzeng E, Ritchie CS, et al. Addressing palliative care
clinician burnout in organizations: a workforce necessity, an ethi-
cal imperative. J Pain Symptom Manage. 2017;53(6):1091-1096.
doi:10.1016/j.jpainsymman.2017.01.007
25. U.S. Bureau of Labor Statistics. Occupational Outlook Handbook:
Home Health Aides and Personal Care Aides. U.S. BLS website.
https://www.bls.gov/ooh/healthcare/home-health-aides-and-per-
sonal-care-aides.htm#tab-1. Published 2019. Accessed February 5,
2020.
26. Marcum A. The 2019 Home Care Benchmarking Study. HomeCare-
Pulse.com. https://www.homecarepulse.com/articles/letter-from-
aaron-marcum-2019-home-care-benchmarking-study/. Published
2019. Accessed June 19, 2020.
27. Schroeder K, Lorenz K. Nursing and the future of palliative care. Asia
Pac J Oncol Nurs. 2018;5(1):4-8. doi:10.4103/apjon.apjon_43_17
28. Fraher E. The Nursing Workforce, Trends and Challenges: Presen-
tation to NCGA Joint Legislative Workforce Development System
Reform Oversight Committee; 2016; Raleigh, NC. https://www.
shepscenter.unc.edu/wp-content/uploads/2016/04/Fraher_
NCGA_3_1_16_FINAL.pdf.
29 Interprofessional Education Collaborative Expert Panel. Core Com-
petencies for Interprofessional Collaborative Practice. Washing-
ton, D.C.: Interprofessional Education Collaborative; 2011. https://
www.aacom.org/docs/default-source/insideome/ccrpt05-10-11.
pdf?sfvrsn=77937f97_2. Accessed April 28, 2020.
30. CFAR Inc., Tomasik J, Fleming C. Promising Interprofessional Col-
laboration Practices. Robert Wood Johnson Foundation website.
https://www.rwjf.org/en/library/research/2015/03/lessons-from-
the-field.html. Published March 10, 2015. Accessed June 19, 2020.
31. Kamal AH, Wolf SP, Troy J, et al. Policy changes key to promoting
sustainability and growth of the specialty palliative care work-
force. Health Aff (Millwood). 2019;38(6):910–918. doi: 10.1377/
hlthaff.2019.00018
32. Palliative Care and Hospice Education and Training Act, HR 647
(2019).
