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Hospice and end-of-life care included in visioning of the future of healthcare


What is the future of health care in the United States? Authors writing for the Journal of the American Medical Association (JAMA) are painting a picture that includes hospice and end-of-life care as central to the next generation of health care practice and patient well-being. In a series of papers recently published in JAMA, authors recommend that the US health care system be restructured to allow more efficient, targeted, and effective delivery of care. A linchpin of this restructuring is learning how to effectively care for individuals experiencing both chronic illness and the end of life.

One paper in particular stands out as a manifesto of sorts for what the US health care system might look like as it more fully integrates hospice and end-of-life care. “Workforce for 21st Century Health and Health Care” is authored by Steven H. Lipstein, MHA, president and chief executive officer of BJC HealthCare, and Arthur L. Kellermann, MD, MPH, dean of the F. Edward Hébert School of Medicine at the Uniformed Services University of the Health Sciences. The article summarizes the findings of the National Academy of Medicine’s writing team, who see a growing role for end-of-life care in the United States.

A large part of this shift in emphasis to providing quality care at the end of life comes as a result of a larger cultural shift in our health care system. Medical professionals, and the public as a whole, say the authors, are increasingly adopting a patient-centric focus in health care. Values, as discerned and expressed by patients and their families, are increasingly driving the development of the health care models that will be critical to health systems in the decades to come.

As part of living into this new cultural and clinical reality, Lipstein and Kellermann envision a new kind of health care workforce. This workforce is interdisciplinary, and prepared to focus care on four distinct types of patients:

1. People who are generally healthy. The generally healthy require health care services, of course, but their needs are generally of a routine nature – checkups, nutritional guidance, immunizations, and encouragement to exercise. Individuals in this category include women who are pregnant and giving birth. It includes young children who, whose health needs are significant, but predictable. “To promote health and prevent minor problems from developing into major ones, physicians, registered nurses, physician assistants, social workers, nutritionists, exercise physiologists, public health and other health professionals, will work together in multidisciplinary teams, and use telehealth and other technologies to extend their reach outside the walls of fixed healthcare facilities.”

2. People experiencing acute and major health episodes. Accidents happen. Auto accidents, falls, heart attacks – all manner of unpredicted, life-threatening events. For these patients, the authors recommend “high volume, high expertise centers” in order to “improve outcomes, reduce costs and improve education of future healthcare professionals.”

3. Individuals who experience ongoing, chronic medical issues. This is the next level of care – those who are neither routinely healthy, nor are experiencing an acute crisis, but who instead exhibit ongoing, chronic conditions that must be managed by health care professionals. The workforce that cares for these patients “should be interdisciplinary, and include paraprofessionals such as community health workers, primary care technicians, and others who can work with chronic diseases.” New technologies, such as home monitoring, will help to simultaneously improve care while reducing medical costs for chronically ill patients.

4. Those who are nearing the end of their natural lifespan. The authors identify the end of life as being a critical time, both for human beings in general, and for the health care system in particular. A different kind of care is needed here than in the other three groups. The authors point to hospice and palliative care as key specialties that will become only more important as the US health care system evolves in the years and decades to come. With nearly 3 million Americans reaching the end of life each year, this is a vital area for growth.

“To improve the care Americans receive in the 21st century, we need to recruit, educate, and sustain a diverse workforce of compassionate health professionals that are comfortable working in interdisciplinary teams, technically skilled, adept at using telehealth and health information technology, and consistently responsive to patients’ needs,” Kellermann said. (JAMA, 9/26,; Science Daily, 9/26,; Medical Xpress, 9/26,