Two Steps Forward,One Step Back: Changes in Palliative Care Consultation Services in California Hospitals from 2007 to 2011

Abstract

Background:

The number of palliative care consultation services is growing, yet little is known about how program characteristics change over time.

Objective:

Compare changes in the characteristics of palliative care programs and palliative care consultation services in 2007 and 2011.

Design:

We surveyed all hospitals in California in 2011 and compared palliative care program and palliative care consultation service characteristics with survey results from 2007.

Results:

There were 41 new palliative care programs since 2007; 17 programs closed between 2007 and 2011. Hospital characteristics associated with the closure of a palliative care program included a hospital size of 1–149 beds versus 150 or more (p=0.03), for-profit status (p=0.001), and having no system affiliation (p=0.0001). The prevalence of palliative care consultation services was 33% in 2007 and 37% in 2011 (p=0.3). At both time periods nearly all palliative care consultation services (98%) were available onsite during weekday business hours and only half were available at other times (p=0.4). There was an increase (p=0.002) in nurse/physician full-time equivalent (FTE; 2007, mean=1.5; 95% confidence interval [CI]=1.3–1.7; 2011, mean=1.9; 95% CI=1.6–2.2) but fewer teams reported having social workers (58% versus 80%, p=0.002) and chaplains (58% versus 77%, p=0.0001) in 2011. Over half of the palliative care consultation services reported seeing less than 50% of patients who would benefit from a consultation (2007: 59%, 2011=50%, p=0.2), yet most also reported struggling to cope with patient volume (2007: 62%; 2011: 66%, p=0.5).

Conclusions:

Fewer than half of hospitals in California offer a palliative care program and many close over time. Making palliative care consultation services a condition of participation by insurers could make hospital palliative care consultation services universal. Mechanisms need to be established to improve staffing levels, maintain the interdisciplinary nature of palliative care consultation services, and accommodate demand for services.

Introduction

Palliative care programs in hospitals improve symptom management, promote patient understanding of treatment options, clarify goals of care, provide psychosocial and spiritual support, and assist with planning postdischarge care.¹ Palliative care is associated with an increase in patient and family satisfaction,^2,3 improvements in quality of life,⁴ a reduction in hospital length of stay,⁵ and a decrease in hospital costs.^2,6 Given the well-documented benefits of hospital-based palliative care programs including improved value of health care and evidence of increasing prevalence of programs over time, there is need to better understand their structure and characteristics,^1,7 to define norms of practice, assist in service promotion and planning, maximize resource allocation within hospitals, identify service features that lead to better patient outcomes, improve efficiency, and promote sustainability.

Our group conducted a statewide assessment of all acute care hospitals in California in 2007 and again in 2011 to identify those with a palliative care program, defined as providing any of a number of palliative care services.⁸ These surveys collected information regarding hospital characteristics and the structure of the palliative care program for those hospitals reporting their presence, as well as details about the structure and characteristics of the palliative care consultation services component of the palliative care program. We report the evolution of the palliative care programs and palliative care consultation services over time; compare service availability, staffing, and patient volume; and analyze factors associated with sustainability to inform further development of palliative care programs and palliative care consultation services.

Methods

Hospitals

Using data from the California Office of Statewide Health Planning and Development (OSHPD) we identified 376 adult and pediatric acute care hospitals that would be expected to offer any type of palliative care service. We excluded rehabilitation, specialty (cardiology, orthopedic), and psychiatric hospitals that would not be expected to provide palliative care services.

Survey

The survey used many of the same items that the survey administered in 2007 did, allowing for direct comparisons across time periods. The survey asked respondents to identify the type of palliative care service provided—palliative care consultation service, inpatient palliative care unit, beds available for palliative care, a primary palliative care service, inpatient hospice beds, or an outpatient clinic—using the definitions adopted by Center for Advanced Palliative Care and described previously.⁷ A hospital was considered to have a palliative care program if it provided at least one of these services. We then inquired about characteristics of each type of service, including when it was established, number of patients seen, disciplines represented, staffing levels and availability and in this report describe detailed data regarding only palliative care consultation services. Hospitals that reported that they did not have a palliative care program were asked to identify barriers they experienced in establishing a program. We also collected descriptive data about each hospital as reported by OSHPD, including number of licensed beds, ownership, teaching status, and system affiliation. The UCSF Committee on Human Research approved the study.

Procedure

The National Health Foundation (NHF) administered the survey with the support of the three hospital councils in California: the Hospital Council of Northern and Central California, the Hospital Association of Southern California, and the Hospital Council of San Diego and Imperial Counties. NHF sent e-mails to each hospital's chief executive officer (CEO) as well as the identified palliative care program leader (if applicable) within each hospital. The emails were addressed from the CEO of the respective hospital council, introduced the survey, and requested that they or the person most knowledgeable about their hospital's palliative care program, such as the program director, director of social services, or chief nursing officer, complete the survey.

Data definitions and statistical analysis

We calculated palliative care consultation services staffing levels and defined a total full-time equivalent (FTE) as the sum of effort dedicated to the service by physicians, advanced practice nurses, registered nurses, social workers, and chaplains. We defined nurse/physician FTE as effort of physicians, advanced practice nurses, and registered nurses. Descriptive statistics (frequencies, mean, median, standard deviation [SD], and range) were used to examine the distribution of measures as appropriate. We used χ² analysis to test for bivariate associations between categorical variables, and analysis of variance (ANOVA) to examine associations between categorical and continuous variables. We used data on staffing from our survey combined with published data on direct cost savings to calculate the estimated return on investment (ROI) for palliative care consultation services. We included only those costs attributable to staffing as palliative care consultation services typically incur few additional costs. We used a value of $150,000 per total FTE as an average of physician, advance practice nurse, nurse, social worker, and chaplain salaries. We multiplied this average cost by average total FTE to generate staffing costs. We multiplied average number of patients discharged alive and those that died in the hospital based on reported data from our survey by published data on direct costs savings per patient⁶ to generate an estimated savings for each population. We summed these savings to determine total estimated savings. By dividing total estimated savings by staffing costs we were we were able to calculate the estimated ROI. The Statistical Package for the Social Sciences (SPSS) for Mac (version 21; SPSS Inc., Chicago IL) was used to analyze these data.

Results

Hospital characteristics

Surveys were distributed to 376 acute care hospitals in California, of which 360 responded to the survey, resulting in a 96% response rate. Hospital size ranged from 10–958 beds, with a mean size of 210 beds (median, 172, SD=149.6). The majority of the hospitals were nonprofit (60.8%, n=219), followed by investor-owned (20.0%, n=72), district (11.9%, n=43), and city/county (5.3%, n=19). Approximately half (55%, n=194) of hospitals reported having a system affiliation and 16.4% (n=59) were teaching sites. Overall, 51% (192/376) of hospitals reported having a palliative care program by offering some type of palliative care service.

Palliative care services over time

There were 170 hospitals with matching data for 2007 and 2011 reporting to have a palliative care program for at least one of the survey periods. Overall, 66% (n=112) of the hospitals had sustained their program from 2007 to 2011, 24% (n=41) of hospitals did not have a program in 2007 and reported the presence of a new program in 2011 (new programs), and 10% (n=17) reported having a program in 2007 that was not sustained in 2011. Of the 41 new palliative care programs since 2007, half (48.8%, n=20) were in hospitals with 150–299 beds, one-third were in hospitals with 300-plus beds (36.6%, n=15), and only 1 in 7 were in hospitals with fewer than 150 beds (14.5%, n=6). The hospitals with new palliative care programs were primarily nonprofit (61.0%, n=25), nonteaching hospitals (70.7%, n=29), and not affiliated with a system (56.1%, n=23).

Table 1 identifies the hospital characteristics associated with sustaining a palliative care program from 2007 to 2011. We found that smaller hospitals, those with for-profit ownership, and those without a system affiliation were more likely not to sustain their palliative care program. Hospitals that were unable to sustain a palliative care program cited a lack of staffing (41%, n=7) and funding (24%, n=4) as the major barriers to having a program.

Table 1.

Association between Hospital Characteristics and the Sustainability of a Palliative Care Program

	Palliative care program status
Hospital characteristics	Sustained n=112 % (n)	Not Sustained n=17 % (n)	χ²	p
Number of beds			7.3	0.03
1–149 beds	71.4 (20)	28.6 (8)
150–299 beds	90.2 (37)	9.8 (4)
300-plus beds	91.5 (54)	8.5 (5)
Ownership			16.6	0.0001
For-profit	53.3 (8)	46.7 (7)
Non-profit	91.2 (104)	8.8 (10)
Teaching site^a
No	83.3 (75)	16.7 (15)	3.2	0.08
Yes	94.9 (37)	5.1 (2)
System affiliation^b
No	76.2 (32)	23.8 (10)	6.2	0.01
Yes	92.0 (80)	8.0 (7)
Struggling to cope
No	96.6 (56)	3.4 (2)	2.2	0.1
Yes	88.9 (32)	11.1 (4)

Teaching site: hosted a residency training program as reported by the National Residency Matching Program.

System affiliation: including three or more hospitals.

Inpatient palliative care consultation services

Overall, 37% (133/360) of hospitals responding to the 2011 survey reported having a palliative care consultation service, similar to the prevalence of 33% (107/324) in 2007 (χ²=1.0, p=0.3). As shown in Table 2, hospitals with 150 beds or more (p=0.0001), nonprofit hospitals (p=0.0001), those that are a teaching site (p=0.0001), and those with a system affiliation (p=0.002) were more likely to have a palliative care consultation service. A comparison between hospitals that reported having a palliative care consultation service in both 2007 and 2011 revealed no significant differences in terms of number of beds (p=0.9), ownership (p=0.4), teaching status (p=0.8), and system affiliation (p=0.9).

Table 2.

Hospital Characteristics Associated with the Presence of a Palliative Care Consultation Service in 2011

	Palliative care consultation service
Hospital characteristic	No % (n)	Yes % (n)	χ²	p
Number of beds			53.7	0.0001
1–149 beds	84.8 (128)	15.2 (23)
150–299 beds	53.8 (57)	46.2 (49)
300-plus beds	41.7 (40)	58.3 (56)
Ownership			56.9	0.0001
Nonprofit	51.1 (112)	48.9 (107)
Investor	93.1 (67)	6.9 (5)
City/county	42.1 (8)	57.9 (11)
District	88.4 (38)	11.6 (5)
Teaching site^a
Yes	22.0 (13)	78.0 (46)	51.0	0.0001
No	71.1 (214)	28.9 (87)
System affiliation^b
Yes	56.4 (110)	43.6 (85)	9.9	0.002
No	72.6 (114)	27.4 (43)

Teaching site: hosted a residency training program as reported by the National Residency Matching Program.

System affiliation: including three or more hospitals.

Census

In 2011, palliative care consultation services reported seeing on average 442 patients annually (median=425; SD=272.8; range, 11 to>1000). This number represents a significant increase (F=7.0, p=0.009) from 2007 (mean=347, median=310, range, 25–933). Similar to 2007, hospital size is associated with census in 2011, with more patients seen by a palliative care consultation services in hospitals with 300 beds or more (496 patients, 95% confidence interval [CI]=135, 422) and 150–299 beds (mean=445, 95% CI=350–540), than at hospitals with 150 or fewer beds (mean=278, 95% CI=135–422). Conversely, the number of patients seen per bed per year was higher in hospitals with 1–149 beds (mean=3.0, 95% CI=1.6, 4.4) than those with 150–299 beds (mean=2.0, 95% CI: 1.6, 2.4) or 300-plus beds (mean=1.2, 95% CI=1.0, 1.4; Table 3).

Table 3.

Relationship between Hospital Size and Overall Staffing and Census and Ratios of Census to Number of Beds and Census to Staffing in 2011

	Hospital size
	1–149 beds Mean (95% CI)	150–299 beds Mean (95% CI)	300-plus beds Mean (95% CI)	F	p
Nurse/physician FTE	n=22	n=41	n=55
Overall	1.2 (0.8, 1.7)	1.7 (1.4, 1.9)	2.2 (1.8, 2.1)	5.4	0.006
Ratio of staffing to number of beds (FTE/100 beds)	1.0 (0.1, 2.0)	0.7 (0.6, 0.9)	0.5 (0.4, 0.9)	16.7	0.0001
Total FTE	n=22	n=41	n=55
Overall	1.8 (1.1, 2.6)	2.3 (2.0, 2.6)	2.9 (2.4, 3.4)	4.6	0.02
Ratio of staffing to number of beds (FTE/100 beds)	2.0 (1.0, 3.0)	1.0 (0.9, 1.2)	0.7 (0.6, 0.8)	19.8	0.0001
Number of patients seen per year	n=16	n=41	n=51
Overall	278.2 (134.9, 421.5)	444.8 (350.0, 539.6)	496.2 (428.2, 564.2)	4.0	0.02
Ratio of census to number of beds (Patients seen/bed/year)	3.0 (1.6, 4.4)	2.0 (1.6, 2.4)	1.2 (1.0, 1.4)	10.7	0.0000
Ratio of census to staffing	n=14	n=35	n=48
(Patients seen/nurse/physician FTE/year)	253.4 (173.7, 333.0)	303.1 (258.5, 347.8)	270.3 (227.5, 318.1)	0.8	0.4
(Patients seen/total FTE/year)	181.1 (107.9, 254.3)	235.0 (192.0, 278.1)	203.1 (171.1, 235.1)	1.3	0.3

CI, confidence interval; FTE, full-time equivalent.

Overall, 50% (62/125) of palliative care consultation services felt they were seeing fewer than half of the patients who would benefit from a consultation in 2011; similar (59%, 62/105) to 2007 (χ²=2.0, p=0.2). In terms of the palliative care consultation service's ability to cope with the current workload, 66% (82/125) of hospitals in 2011 reported that they were struggling to cope which was similar to the percentage in 2007 (61%, 63/103) (χ²=0.5, p=0.5).

Staffing disciplines and palliative care consultation services

Hospitals in 2011 reported that their palliative care consultation services was comprised of physicians (85%, n=104), registered nurses (63%, n=77), social workers (58%, n=71), chaplains (58%, n=71), and advanced practice nurses (46%, n=56). Compared to 2007, there were no significant differences in the proportion of palliative care consultation services with physicians (p=0.7), registered nurses (p=0.2), or advanced practice nurses (p=0.8). However, compared to 2007, in 2011 fewer palliative care consultation services reported having chaplains (58%, n=71 in 2011 versus 77%, n=82 in 2007; p=0.003) and social workers (58%, n=72 in 2011 versus 80%, n=86 in 2007; p=0.0001). In 2011 only 45% of palliative care consultation services teams were comprised of clinicians from 4 or more disciplines, compared to 61% of teams in 2007 (p=0.02)

Palliative care consultation services availability

For both years almost all palliative care consultation services were available on site during weekday business hours (9:00 am to 5:00 pm). Overall approximately half of palliative care consultation services were available after business hours on weekdays and any time on weekends with the vast majority available by phone and only a small minority available on site.

Staff total FTE and nurse/physician FTE

A total of 94 (87.9%) hospitals in 2007 and 122 (91.0%) in 2011 provided information regarding the level of staffing dedicated to the palliative care consultation services. The mean total FTE for 2007 was 2.2 (median=2.0, SD=1.3, range, 0.7–7.0); for 2011 the mean total FTE was 2.6 (median=2.3, SD=1.9, range, 0.1–13.0). This slight increase in total FTE was not statistically significant (F=3.7, p=0.06). There was, however, a significant increase (F=5.8, p=0.02) in the nurse/physician FTE from 2007 (mean=1.5, median=1.5, SD=0.9, range, 0.2–4.0) to 2011 (mean=1.9, median=1.5, SD=1.4, range, 0.1–8.0). While larger hospitals reported having more FTE overall, smaller hospitals had a higher ratio of nurse/pPhysician FTE and Total FTE per 100 beds compared to larger hospitals (Table 3).

In 2011, palliative care consultation services saw an average of 208 patients per total FTE per year (median=184, SD=119, range: 10–495) compared to 188 in 2007 (p=0.3) and an average of 276 patients per nurse/physician FTE per year (median=250, SD=141,range:10–631) compared to 258 in 2007 (p=0.4). There were no differences based on hospital size (Table 3).

In 2011, palliative care consultation services that reported having difficulty coping were seeing more patients overall, more patients per total FTE and more patients per nurse/physician FTE than those that felt they were able to cope (Table 4). Overall, palliative care consultation services that reported that they were struggling to cope saw a mean of 489.2 (95% CI=433.4, 545.0) patients per year compared to a mean of 363.7 (95% CI=284.8, 442.6) patients for palliative care consultation service that felt they were able to cope (F=5.5, p=0.02).

Table 4.

The Association between the Perceived Ability to Cope with Patient Volume and the Structure of the Palliative Care Consultation Service by Year

	Struggling to cope
	No Mean (95% CI)	Yes Mean (95% CI)	F	p
Palliative care consultation service structure
Census 2011 (patients/per year)	363.7 (284.8, 442.6)	489.2 (433.4, 545.0)	5.5	0.02
Census/staff ratio
Total FTE ratio^a
2007 (n=72)	133.2 (91.0, 175.4)	220.2 (188.6, 252.0)	11.3	0.001
2011 (n=101)	154.4 (118.1, 190.8)	238.7 (212.2, 265.2)	13.1	0.0001
Nurse/physician FTE ratio^b
2007 (n=72)	190.0 (135.8, 244.0)	297.3 (256.6, 338.0)	9.4	0.003
2011 (n=101)	236.2 (189.6, 282.8)	301.3 (267.3, 335.2)	5.1	0.03

Number of patients seen a year per total FTE includes staffing for physicians, advanced practice nurses, registered nurses, social workers, and chaplains.

Number of patients seen a year per nurse/physician FTE includes staffing for physicians, advanced practice nurses, and registered nurses.

CI, confidence interval; FTE, full-time equivalent.

Patients cared for by palliative care consultation services

We found that there were no significant differences between the year in which the survey was undertaken (2007 or 2011) and the location of patients at the time of referral to the palliative care consultation service. For both years the majority of palliative care consultation service referrals were for patients who were on an acute medical-surgical unit (2007=55%, 2011=50%, p=0.1), followed by intensive care units (2007=29%, 2011=31%, p=0.5), step-down or transition units (2007=7%, 2011=8%, p=0.5), subacute units (2007=3%, 2011=3%, p=0.1), emergency departments (2007=3%, 2011=3%, p=1.0), and outpatient clinics (2007=2.0, 2011=1.0, p=0.4).

We found similarities in discharge disposition across hospital size with those hospitals with 1–149 beds reporting discharging 74% (238) of patients alive, while 26% (83) died in the hospital. Hospitals with 150–299 beds discharged 75% (293) of patients alive and 25% (98) died in the hospital; those with 300-plus beds discharged 70% (330) of patients alive and 30% (144) died in the hospital.

Return on investment

We calculated estimated costs for total FTE for hospitals with 1–149 beds, 150–299 beds, and 300-plus beds (Table 5). We then calculated estimated direct costs savings for palliative care consultation services based on numbers reported above using published savings of $1,696 per patient discharged alive and $4,908 per patient who died in the hospital.⁶ Dividing estimated total savings by staffing costs provides an ROI of 3.0 for hospitals with 1–149 beds, 2.8 for hospitals with 150–299 beds, and 2.9 for hospitals with 300-plus beds. Based on these calculations, palliative care consultation services would break even if they saw as few as 33% of the average annual census reported in our survey.

Table 5.

Annual Return on Investment for Palliative Care Consultation Service by Hospital Size

			Direct cost savings for patients referred to a palliative care consultation service					ROI
Bed size	Total FTE	Staffing costs ($150K/FTE) ($)	Discharged alive (n)	Savings^a ($1,696/patient) ($)	Died (n)	Savings^a ($4,908/patient) ($)	Estimated total savings ($)	\documentclass{aastex}\usepackage{amsbsy}\usepackage{amsfonts}\usepackage{amssymb}\usepackage{bm}\usepackage{mathrsfs}\usepackage{pifont}\usepackage{stmaryrd}\usepackage{textcomp}\usepackage{portland, xspace}\usepackage{amsmath, amsxtra}\pagestyle{empty}\DeclareMathSizes{10}{9}{7}{6}\begin{document} $$ \frac { Estimated \ Total \ Savings } { Staffing \ costs } $$ \end{document}
1–149	1.8	270,000	238	403,648	83	407,364	811,012	3.0
150–299	2.3	345,000	293	496,928	98	480,984	977,912	2.8
300+	2.9	435,000	330	559,680	144	706,752	1,266,432	2.9

Data from Morrison et al.⁶

FTE, full-time equivalent; RO, return on investment.

Discussion

There has been little change from 2007–2011 in the number of California hospitals that offer a palliative care program or a palliative care consultation service. We found that during this period there were 41 newly established palliative care programs, largely in nonaffiliated, nonprofit hospitals with more than 150 beds, and 17 that failed, of which most were in small, for-profit hospitals not affiliated with a system. Interestingly, palliative care consultation services that reported that they were struggling to cope were not more likely to fail. While workload was not associated with failure, staffing and funding were cited as barriers to developing a palliative care program. A shortage of board-certified nurses and physicians is a challenge to starting a palliative care program. Identifying current staff with interest and ability in palliative care and supporting them to get additional training may help overcome this barrier. It is interesting to note that hospitals identified lack of funding as a barrier given that our analysis shows that for any hospital size a palliative care consultation service provides a significant ROI. While it may be challenging to allocate funds to a new program when budgets are tight, using published cost savings⁶ and average salaries, we found that the ROI would be significant, immediate, and robust. A palliative care consultation services would break even in the first year if it cared for only one-third of the average number of patients typically seen by a palliative care consultation services in its size hospital. These results should reassure hospital leaders that they can afford to establish a palliative care consultation service that is highly likely to improve the quality of care and add value.

While the prevalence of hospital palliative care programs grew in the period from 2000 to 2007,⁷ since 2007 there has been little net increase and still only half of acute care hospitals in California offer any type of palliative care service. While small, for-profit, and non-system–affiliated hospitals are less likely to report having a palliative care program, in absolute terms there are still many large, nonprofit and system-affiliated hospitals without a program. Given the proven benefits to quality associated with various palliative care services,^4,9–11 including palliative care consultation services, all hospitalized patients should have access to a palliative care consultation service. Strategies such as encouraging private insurers, Medicare and Medicaid to make offering a palliative care consultation service a condition of participation as well as public reporting of the presence of a palliative care consultation services, as has been instituted in California as part of the OSHPD annual hospital survey, could help to achieve the goal of universal access to a palliative care consultation services for hospitalized patients.

Promoting sustainability of a palliative care consultation service may be enhanced by demonstrating value at the hospital level. Data showing improved quality at no extra cost or even associated with cost savings with a robust ROI make a powerful case for financial support of a palliative care consultation service. The finding that 42% of referrals to the palliative care consultation services are from high intensity settings such as intensive care units, step-down units, and emergency departments proves that there are opportunities to impact resource utilization.¹² In fact, palliative care consultation services have been effective in assisting specific service lines to achieve their goals more effectively.¹³ Providing palliative care following hospital discharge has also been shown to be an important factor in reducing hospital readmissions,^11,14 and the potential for prolonged life.¹⁵ There is a burgeoning body of literature demonstrating the financial and clinical benefits for a hospital to establish and sustain a palliative care consultation service.^4,11,9,10 To promote ongoing support, palliative care consultation service leaders should report their quality and cost outcomes regularly to hospital and system leadership.

Despite an increase in nurse/physician FTE overall, palliative care consultation services reported being busier, most are struggling to cope, and the majority feel that there are many more patients that would benefit from a palliative care consultation service consultation. Care needs to be taken to avoid the risk of burnout from overwork and understaffing in a field already at risk as a result of the emotionally challenging nature of the work. While our data suggest that struggling to cope is not associated with palliative care consultation services failure, it would be naïve not to be concerned about burnout. In addition, our results provide normative data for staffing and census by hospital size that can guide new palliative care consultation services. We found that in smaller hospitals palliative care consultation services are proportionally better staffed and see more patients per bed than teams in larger hospitals. It may be that in smaller hospitals palliative care consultation services are better able to market their service and more likely to know, have a personal relationship with, and reach out to referring clinicians. The ratio of patients seen per bed in the smaller hospitals suggests a benchmark that larger hospitals might attain with sufficient staffing.

Another concern is that palliative care consultation services have become less interdisciplinary with fewer teams including chaplains and social workers in 2011 compared to 2007 and most are still not available 24/7. Palliative care is fundamentally interdisciplinary and needs to be in order to address the range of issues that matter most to patients and families.¹⁶ The National Quality Forum's framework and preferred practices for palliative and hospice care quality¹⁷ and Joint Commission Advanced Certification in Palliative Care require an interdisciplinary team and 24/7 availability.¹⁸ In our survey, only half of hospitals reported having a team consisting of four or more disciplines, down from nearly two-thirds in 2007, and still only half reported being available 24/7. With a reduction in staff composition and lack of availability, especially on weekends, it becomes increasingly difficult to adequately meet the needs of patients with serious illness and their families.

Our findings should be tempered by the following limitations. Our survey relied on self-report information that has potential inaccuracies resulting from poor recall or limited access to information about palliative care consultation service structures and processes of care. These potential sources of error were mitigated by our efforts in both survey years to distribute the survey to individuals who would be most knowledgeable about their hospital's palliative care program. In addition, not all respondents answered every question. We addressed this potential limitation by reporting only those items with a sufficient number of responses to be meaningful. Finally, due to the small number of palliative care consultation services that were not sustained, potentially significant associations may not have been detected.

Palliative care is increasingly recognized as an essential component of care for hospitalized patients with serious illness and their families. Policies that mandate palliative care consultation services in hospitals could ensure universal access to palliative care consultation services. Ultimately, while published data demonstrate that palliative care consultation services provide value, each palliative care consultation services will need to demonstrate value to their patients, referring clinicians, institutions and health care systems to advocate for additional support to address unmet need and ensure long-term sustainability.

Footnotes

Acknowledgment

We thank the Hospital Council of Northern and Central California, the Hospital Council of Southern California, and the Hospital Council of San Diego and Imperial Counties for their support in encouraging their members to participate. We acknowledge Kathleen Kerr for the invaluable contribution she made to survey development and dissemination. Finally, we thank all of the respondents for their diligence and care in responding to the survey. The California HealthCare Foundation funded this study.

The California HealthCare Foundation provided funding to support the administration of the survey and analysis of findings, as well as limited dissemination of results though the Foundation's communication venues.

Author Disclosure Statement

No competing financial interests exist.

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