Abstract：
Background: Among patients with serious illness, palliative care before hospice enrollment is associated with improved quality of life, reduced symptom burden, and earlier transitions to hospice. However, fewer than half of eligible patients receive specialty palliative care referrals. As most hospice clinicians and administrators have experience in specialty palliative care, several emerging programs propose engaging hospice clinicians to provide early palliative care. Objective: We sought to identify barriers and facilitators to upstream palliative care. Design: We conducted a key informant qualitative study among hospice administrators and clinicians. Setting/Subjects: We conducted semi-structured interviews with 23 hospice administrators and clinicians in eight states from March to August 2022. We identified participants using snowball and purposive sampling using states that participate in Medicare Advantage\'s value-based insurance design Model. Results: Respondents indicated that barriers to early palliative care included inadequate staffing and reimbursement. Hospice clinicians providing community-based palliative care can address access barriers and improve transitions to hospice. Respondents expressed desire for payer guidance in identifying eligible patients but were cautious about payers acting as direct palliative care providers. However, payers could facilitate uptake by broadening and specifying coverage of services to include goals of care conversations and symptom management. Routine referrals initiated by objective measures could potentially increase access. Conclusions: Utilizing hospice providers to provide upstream palliative care can increase access, improve outcomes, and ease the transition to hospice.
摘要：
背景：在患有严重疾病的患者中，临终关怀登记前的姑息治疗与生活质量的提高有关，减轻症状负担，和早期过渡到临终关怀。然而,不到一半的符合条件的患者接受专业姑息治疗转诊.由于大多数临终关怀临床医生和管理人员都有专业姑息治疗的经验，一些新兴计划建议聘请临终关怀临床医生提供早期姑息治疗。目标：我们试图确定上游姑息治疗的障碍和促进因素。设计：我们在临终关怀管理人员和临床医生中进行了一项关键的信息定性研究。设置/主题：我们于2022年3月至8月对8个州的23名临终关怀管理人员和临床医生进行了半结构化访谈。我们使用滚雪球和目的性抽样，使用参加MedicareAdvantage基于价值的保险设计模型的州来确定参与者。结果：受访者表示，早期姑息治疗的障碍包括人员配备不足和报销。提供基于社区的姑息治疗的临终关怀临床医生可以解决访问障碍并改善向临终关怀的过渡。受访者表示希望在确定合格患者时提供付款人指导，但对付款人充当直接姑息治疗提供者持谨慎态度。然而,付款人可以通过扩大和指定服务范围来促进接受，以包括护理对话和症状管理的目标。由客观措施发起的例行转介可能会增加获取机会。结论：利用临终关怀提供者提供上游姑息治疗可以增加获取，改善结果，轻松过渡到临终关怀。
