Health on the Map: Understanding the Impact of Palliative Care

Mount Marty University President, Marc Long, recently joined Michele Snyders for "Health on the Map," a podcast that explores rural health care in the United States. She is a Hospice and Palliative Care Program Manager for the South Dakota Association of Healthcare Organizations (SDAHO). Snyders has many years of experience in the healthcare field including working in hospitals, social work, solid organ transplant, dialysis, palliative care and telehealth in the long-term care setting. She was the first social worker in South Dakota to successfully pass the Advanced Palliative and Hospice Social Work exam. At SDAHO, Snyders facilitates Life Circle South Dakota, a group of healthcare professionals focused on improving end of life care through education and lobbying efforts.

This conversation has been taken from the original podcast and edited for length and clarity.

president marc long: First off, what is the difference between palliative care and hospice?

Michele Snyders: Great question, Marc. That's one of the things that is probably the biggest misconception: that palliative care and hospice care are synonymous, and they're not. They're very different. Everything that hospice care does is considered palliative, which is why there's a confusion. To palliate means to make somebody feel better, which is the focus of both of the entities. But palliative care has a much larger specialty. So it can follow somebody with from the moment of a serious illness diagnosis throughout the trajectory of the disease. For example, the patient can be getting curative treatment while we can support them with symptom management. We have goal of care conversations to make sure that the treatment that they're receiving is still consistent with their values and preferences, and then we always reevaluate where the plan is going to make sure that it fits what the patient wants.

We can also help with the transition to hospice if the disease is a terminal diagnosis. And when they get more to the end stage of the illness, that's when hospice would become involved with the patient. So hospice really focuses on the final six months of a patient’s illness as determined by the physician. And at that point in time, the patient and family may have decided that curative treatment is becoming more burdensome. They may just want to focus in on just really great symptom management and allowing the disease to take its natural course through the end of my life. 

Sure. So palliative care can be years, maybe even decades. 

Correct.

Whereas typically hospice care is finite, you said really that last six months or so.

Yes, yes. 

Good. I know palliative care is getting a lot of attention these days, partially because we have an aging population, and I think there are more issues that obviously we see later in life. As baby boomers age, we're seeing that. I think policymakers are paying attention to that more and more. Can you talk about some of the latest policy developments, either at the state or federal level that have improved palliative care in our region?

Absolutely. Across the nation, there's been a movement among states to try to bring better reimbursement for health care providers to bring palliative care to patients, specifically home-based palliative care. And that population is going to capture patients that have a serious illness that are going in and out of the hospitals, going to the emergency rooms, and trying to manage their disease that way. They don't qualify for home care because they don't really have a skilled need—home care is a very finite resource as well—and they don't meet the hospice criteria because they're not at that end part of the disease or they don't have a terminal diagnosis. But they're the higher utilizers of healthcare delivery in states. So, states across the nation have started coming up with reimbursement for palliative care teams to go into a person's home and support them to try to manage their symptoms better, more quickly, but also to make sure that the entire person is taken care of, which is what the basis of palliative care is. It's delivered by an interdisciplinary team. You're making sure you're taking care of the physical part of the person, but also their emotional, their spiritual and their social determinants of health that may cause them to not be able to access care or the things that they need to stay healthy in addition to their medical care.

In South Dakota, specifically this last year, we started looking at how can we help take care of our residents in their home, especially in light of the nursing home closures that have happened in our state over the last several years. There was a long-term care summer study, legislative summer study that was held and tried to take a look at what are some alternatives if we would continue to lose our long-term care facilities. And one of them was boosting home-based services, and that included home-based palliative care. So we did pass legislation in our state to put in a definition of what palliative care is—and that's the first step to really identify what is palliative care—and who can get palliative care. Then the next steps moving forward will be how do we access reimbursement so that the healthcare providers that want to deliver this care can get reimbursed for the entire interdisciplinary team to provide those services.

Yeah, so let's talk a little bit about that. You talked about the long term care facilities that are closing in the state. How has that really impacted palliative care? And I understand sometimes you can do the in-home care, but sometimes you can't. You need to have more skilled facilities. How are we addressing that in South Dakota and, I would assume, other states in the Midwest? How are we addressing that critical issue as our population ages?

That was the whole purpose of the summer study. We're researching bringing a PACE program to the state of South Dakota to see if that can help capture some of those patients. That if they were displaced from a nursing facility, how can we bring those services to them in the home? The patients that have more medical needs, those needs could be met in the home setting rather than them having to leave a facility that's closed and move 30, 60, 90, 100 miles away from their support systems, their communities. So really trying to keep people focused in their home communities and bringing the care to them is one of the options that we're taking a look at.

Great. That's wonderful. So we have the definition now, and you're hoping that the money to these teams will then follow. What else needs to else needs to happen?

You know, from a federal perspective, it would be nice if there would be more federal movement to get reimbursement through the Medicare system and from an insurance perspective. Again, the biggest gap is the whole reimbursement for the interdisciplinary team. Right now, physicians, nurse practitioners and PAs are the only ones that can bill for their time to see a palliative care patient. But when you're bringing in the nurses, the social workers, the chaplains, the pharmacists to provide that wraparound, whole person care, there's no reimbursement for their time. So really trying to get an actual benefit that's available that would reimburse organizations to allow for the entire team to be reimbursed would be probably the next step.

Let's pivot this a little bit, if we can, to health care systems in South Dakota. We've talked a little bit about the need for home care, but how are the health systems addressing palliative care needs in innovative ways?

Well, in the state of South Dakota, as you know, we're rural, we're frontier. Most of our counties are considered frontier when you take a look at population based. And we have a limited number of palliative care providers in our state. Right now, we only have about 12 practicing with a couple more that are being recruited and will be coming to our state.

But when you take a look at our population of over 900 ,000, 12 to 14 providers is not a lot to cover that care. We have a lot of unmet palliative care needs in our state simply from lack of providers. So trying to increase training and education for other healthcare providers to at least have some basic skills, some basic knowledge, to bring what's called primary palliative care to everybody in our state. 

We have organizations that are doing some training. We have an organization up in Eagle Butte that just received access to the CAPC, which is the Center to Advance Palliative Care. They're going to get a membership which will allow them to train their staff to provide basic palliative care to be able to manage symptoms, to be able to have goals of care conversations, to develop those skills and bring it to an area of our state that's unmet. 

So that's one innovative thing that's happening. Really in our small rural access facilities, we’re trying to encourage them to do education and training, which is why our state actually has a statewide program called Life Circle South Dakota that focuses in on public policy, professional education and public education about serious illness care. And that's one of the things that we try to strive for is to bring education to healthcare professionals on some basic palliative care skills.

I know you were talking about different places around the state. I know Avera Medical Group here locally in Yankton has started a palliative care service model, I guess, with Dr. Katie Huff, who is one of those specially trained individuals. She's also on our nurse practitioner faculty. She's a nurse practitioner at Avera Sacred Heart Hospital, and I know that that is new within the last couple of months that they've actually started that program here in Yankton. So, we're pretty excited about that.

Yeah, she's been a huge champion for palliative care. She has been able to bring palliative care into the long-term care facilities as well down in the Yankton area, which is a huge population that would benefit from having palliative care. She's a fabulous champion in our state.

So obviously we have a pretty big nursing program at Mount Marty University. And one of the things I spend a lot of time dealing with from a lot of health care systems and others is this shortage of nurses, primary care physicians, social workers and a lot of other professionals and providers, especially in rural areas. How does that shortage of those providers impact palliative care throughout the region?

Well, there's competition among which areas they're going to go into. And so the limited number of nursing students, social work students, physicians and residents going into that, trying to encourage them to look at palliative care as a specialty practice and getting some basic education and training at that level so that they can at least take some basic skills. Maybe they're gonna work in ICU, but what a great area for a nurse to have basic palliative care skills in and also to be able to serve those patients in an ICU setting. The more education we can get to the student population to bring with them on basic skills is gonna help grow at least good conversations, good recommendations for symptom management. All of that can help if we get those students trained across the board with some basic education.

The specialty training is a whole other area: to get fellowship trained as a physician, to get certified in hospice and palliative care as a registered nurse or as a certified nurse practitioner. There are so many specialty areas that can get certified in hospice and palliative care that if a person really wants to provide in that more specialized service under the palliative care, getting that certification and moving on beyond their basic training would be very important. There are just not enough people out there to fill all of the needs that need to be met across the healthcare systems.

For sure. And I'm guessing part of that is the responsibilities of the colleges and universities, the schools of nursing, the schools of medicine and other programs to make sure that the exposure is there either in the undergraduate or the professional programs. Do we have colleges and universities in South Dakota who are bridging that gap and doing it well?

Yeah, absolutely. Well, Mount Marty itself was part of a HRSA grant that. The grant ended in 2023, but the focus of that HRSA grant was to bring nursing curriculum to a few of the colleges that were partners with that grant, which included Mount Marty and Presentation Sisters—sorry, I can't remember. There were three universities that were involved. 

South Dakota State and Avera? Were they involved in that too, maybe? 

Yes, yes! That's who it was. So, nursing curriculum was developed and instituted in that. Since that grant has ended there's now a mandate for nursing schools to have palliative care curriculum so all universities and academic centers with providing nursing education must have palliative care curriculum as of this past year. That's a step forward in getting that basic education in there. We're looking forward to see what happens with that curriculum development as that continues. 

Michele, anything else that we should talk about regarding palliative care?

When I first started in palliative care a long time ago, I had a physician that said, “Once you learn palliative care, you won't see medicine done any other way.” And part of that is because of the great communication skills that have to happen, really sitting down with the patient, finding out who they are, what's important to them, what are they willing to go through, what are they not wanting to go through and creating an individualized plan of care that takes care of that whole person. When you see that kind of medical care being provided to an individual, you're like, “That's what healthcare should be across the board.” 

I think it's really important for the public to understand what palliative care is, how it can help their loved ones and to ask for it. To find out where can I go in our state to get palliative care? If it's not available to me, who in our community has some training that I can visit with? Can we get connected via telehealth, which is a great resource across our state. 

Getting the public to advocate and learn about it, to not be afraid of it. It is not hospice care. And then to get the healthcare professionals to fully understand. So that if you've got a cardiology patient that's got some serious heart issues and having a lot of symptoms from the disease itself, maybe some from the treatment that they're receiving, they can learn that if I refer my patient to a palliative care professional, that professional is going to work hand in hand with me to make sure that my patient is getting the best care possible. I'm not sending them over to hospice. We don't have to stop providing the cardiology care, but they're going to work in tandem with me. If we do this, we're going to have better utilization of palliative care across our state. 

Michele Snyders, thank you for spending time with us today and good luck to all the important work you're involved in.

Thank you so much for allowing me the opportunity to talk about this really important healthcare.

"Health on the Map" is a production of Mount Marty University Nursing and is available for streaming on Spotify, Apple Podcasts and YouTube. To learn more about Mount Marty, South Dakota's Catholic University, visit mountmarty.edu/nursing.

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