Melanie Cole (Host): Welcome to Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole, and I invite you to listen as we discuss palliative care at the Carle Foundation Hospital. Joining me is Dr. April Yasunaga. She's a Palliative Care Physician at the Carle Foundation Hospital. Dr. Yasunaga, thank you so much. What a great topic this is. Tell us first, as you're telling us the difference between palliative care and hospice care, and people hear these terms thrown about, what palliative medicine really is. Give us a little bit of the evolution of it and the difference between that and hospice care.

Judith (April) Yasunaga, MD (Guest): I like the definition that the World Health Organization gives about palliative care, that it's an approach to improve the quality of life of patients and their families facing problems associated with life threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.

So it's a very broad and can care for patients that are pursuing disease focused treatment as well as more symptom focused treatment, whereas hospice care, is often, I think of it more as a philosophy of care that has been defined as affirming life and exists to provide support and care for terminally ill persons or patients with the aim of alleviating suffering and augmenting quality of life.

And so in the United States, that most looks like how, it's been considered in terms of patient eligibility for Medicare Hospice Services. So, that often means a life expectancy of six months or less, if their terminal illness were to run its expected course, as well as, not pursuing life-prolonging or disease curative type treatments and the benefit that goes along with that.

So all of hospice care is palliative, but not all of palliative care is hospice. And I think that gets confused frequently.

Host: That's an excellent way to put it because that's where some of that confusion lies. Now, I'd like you to speak about the benefits of palliative care and sort of the goals of what it's done, but there are some myths and misconceptions. People, and especially the families don't know what palliative care is and they think it's just that end of life.

So I'd like you to speak about the benefits and how somebody really gets into a program of palliative care. What is it doing for the patient?

Dr. Yasunaga: So, the goal of palliative care is to provide or improve or support quality of life as patients are going through their experience with their serious or life-limiting illness. So, what palliative care has been shown to do is reduce readmissions to the hospital and reduce overall costs.

In the outpatient sector, it's been shown to help reduce admissions and ED visits and, you know, patients, they want to spend their time, not in a hospital or an acute care setting. For skilled nursing patients, it's also been shown to help to reduce time spent to the hospital or ED admissions, and reducing cost.

And in some disease states it's been shown to provide length of life. So, those are some of the benefits. I think also, being more than just patient focused, but also caregivers and family, whatever that individual might consider family or their support group, providing support for them as well.

Host: Well, that leads very well into my next question. So, how can palliative care providers help family issues? Now, first of all, families don't always know what their role is once a palliative care physician gets involved and what their next steps should be. How they even start that discussion with their loved one. Tell us a little bit about how you work with the families, and as you're telling other providers, so that they can counsel their families as well.

Dr. Yasunaga: So, the hope with palliative care is to be comprehensive and we recognize that for a lot of patients, especially as they go through their trajectory of their illness, that their caregivers or their, however they define their family is going to be a large part of their care, their direct physical care. So, I think, our role, particularly in our office, is being a resource to those caregivers, and if something has changed for the patient, to call and be able to have the guidance of maybe what resources they should tap into or transitions of care, being another significant area to kind of guide patients and their families through, when maybe the physical needs of that patient stretches maybe what they're able to provide and what kind of resources are reasonable for them, if keeping them at home is important or is it time to transition to more skilled care facility? So, helping to be that sounding board and in that resource to have some of those discussions as patients are cared for by their family and their loved ones.

I think the other thing we can tap into is, kind of that multi-disciplinary approach and accessing our spiritual care and therapists, social workers, to try to help meet the needs because frequently what a patient and their family needs may not be what a prescription can provide. It may be that they need physical therapy or occupational therapy, or maybe they need speech therapy, or they need a social worker to help navigate how they're going to get their medications most cost-effectively or find access to additional in home care and things like that.

Host: Well, thank you for that. And as we're talking about resources available to build these palliative care skills for other healthcare providers, I think another big question that they're going to get quite often is about insurance. Does it cover palliative care and even hospice care for that matter? Tell us a little bit about that realm of this, because those, those have to be discussions that are had. Yes?

Dr. Yasunaga: So, palliative care is covered by most insurance companies, much like going to see any other subspecialty in medicine. So, very similar to going to seeing a pulmonologist or cardiologist or, or something along those lines. So, paid along the ways as other specialty care is. And for most insurance companies, then requires a referral to our office.

Patients frequently will call our office to ask about engaging in our understanding more and sometimes we can help to navigate, or reach back out to their primary care to see if a referral makes sense for that patient. So, very similar to seeing other medicines specialty groups or departments. So hospice care is different. And I think the model that we most commonly think of is the benefit through Medicare. So, it is a Medicare benefit that, when you access that benefit, then, you engage in the services provided in a hospice entity that has been approved by Medicare.

And then you're, provided specific resources for that. So, there's nursing care, and aide care, pastoral care, nursing care, et cetera, et cetera. So, that is different because it is a defined Medicare benefit. And that's probably what we most commonly think of in the United States of what hospice, the delivery of care looks like.

Host: So before we wrap up, if somebody is a candidate for palliative care, how do they find a physician such as you? Does a primary care physician refer? Do they have a nurse navigator? How does this all start? Tell us about getting involved in it.

Dr. Yasunaga: So, a lot of our patients are referred to by subspecialty medicine services, so maybe cardiology, pulmonology, or an oncologist that are following them. And they have a specific, reason that we might be helpful, like pain management or something along those lines. So, we'll get referrals from specialty medicine groups as well as from primary care physicians. So, really anybody taking care of the patient can refer to palliative care. And then the Carle Healthcare System, that's putting in a consult order through our electronic medical record. But they could also call our office and we're very fortunate to have excellent nurses that can help to navigate completing that referral, getting it in or discussing further whether palliative care would be a good resource for that patient.

And I think to also emphasize that with palliative care, you're continuing with all of the other providers that may be engaged with that patient. In contrast with hospice care where often the focus really becomes comfort directed care towards the end of life. And that often means that the patient is no longer, maybe seeing their sub-specialty medicine groups, maybe it's the oncologist or the pulmonologist routinely.

Host: Well, it certainly is so important to have that multidisciplinary approach when we're talking about palliative care. As we wrap up, how other providers, what you would like them to know about palliative care medicine and what you're doing at the Carle Foundation Hospital?

Dr. Yasunaga: At Carle, we're fortunate to have a growing department and provide outpatient as well as inpatient services, which I think is particularly in the outpatient sector, a place where we've been growing. We do have the ability to do virtual visits or telephone visits, which I think had become necessary because of the pandemic.

So, I think that helps to get a little bit of a larger outreach, in terms of geography, because we're kind of spread out here in central Illinois. And also I think it helps to make follow-ups and things a little bit easier for patients that they're not having to travel and come into a clinic.

So, I think those are some areas that have been beneficial, or we've been able to grow. I will stress that, I think, Carle has done a good job. We have aninstitutional membership to CAPC, which is the Center to Advanced Palliative Care. So that's something that every physician provider, at Carle with the Carle email address has access to registering and there's modules in there to help to develop palliative care skills and from the primary palliative care, regard. So, I think that's a very useful resource that we all have access to as well.

Host: That is an excellent resource. And thank you so much for pointing it out. And thank you again for joining us today and sharing your expertise on palliative medicine, Dr. Yasunaga. Thank you. For more information, and to get connected with one of our providers, you can always visit carle.org. Or for a listing of Carle providers and to view Carle sponsored educational activities, head over to our website at carleconnect.com. That concludes this episode of Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole. Thank you so much for listening.