Health Care Provider Barriers to Patient Referral to Palliative Care

Abstract

Objective: The purpose of this study was to explore healthcare provider-perceived challenges to HBPC patient referral and elicited providers’ feedback for overcoming these challenges. Methods: We conducted a qualitative study using semi-structured interviews with 25 Medicaid managed care providers (primary care physicians, nurse practitioners, and care managers) working in the greater Los Angeles area. Our interview protocol elicited providers’ knowledge and awareness of palliative care; perceived barriers to HBPC referral; and suggestions for overcoming these barriers. We analyzed verbatim transcripts using a grounded theory approach. Results: Themes related to referral barriers included providers’ lack of palliative care knowledge and clarity regarding referral processes, provider reluctance to refer to HBPC, and provider culture. Providers also identified patient-level barriers, including financial barriers, reluctance to have home visits, health literacy, cultural barriers, and challenges related to living situations. Themes related to methods for overcoming challenges included increased HBPC education and outreach to providers, specifically by HBPC agency staff. Conclusions: Findings from this study underscore the need for additional palliative care education for Medicaid healthcare providers. They point to the need for novel strategies and approaches to address the myriad barriers to patient identification and referral to HBPC.

Reluctance to Accept Palliative Care and Recommendations for Improvement: Findings From Semi-Structured Interviews With Patients and Caregivers

“…In keeping with findings from previous research, 13 our findings showed that patients and caregivers' lack of palliative care knowledge was a barrier to HBPC use. It should be reiterated that all patients eligible for this study (and the earlier RCT) were diagnosed with cancer, COPD, or congestive heart failure, reported significant functional decline, and reported a recent emergency room or hospital admission.…”

“…In recent research, primary care providers also have identified this reluctance as a potential patient barrier to receiving HBPC. 13 Home healthcare agencies have cited invasion of privacy, fear of the unknown, and managing care at home as the most common reasons for refusing care at home. 27 Notably, the recruitment for the larger RCT took place prior to the start of COVID-19 as did the majority of the interviews for the current study, therefore COVID-19 most likely did not influence responses.…”

“…Yet recent reports suggest that insurance coverage for palliative care may be insufficient to expanding patient access to HBPC. 12,13 Previous research examining obstacles to the delivery of palliative care among healthcare professionals helps explain the persistent lack of patient referral and subsequent enrollment in HBPC programs. 14,15 In this study, we explored palliative care barriers from the perspective of patients and their caregivers who had been previously recruited and were eligible for palliative care under a randomized controlled trial (RCT).…”

Advances in systemic therapy for non-small cell lung cancer

“…Despite improved outcomes with integration of the palliative care team, this remains substantially underused for many patients 113114. Barriers to palliative care referral identified by physicians include misunderstanding the role of the palliative care team,112115116 concerns that a patient may lose hope,112 and institutional culture 115. Physicians perceived patient related barriers to palliative referral as including financial, health literacy, and cultural aspects, the patient’s living situation, and disinclination for home visits 115.…”

“…Barriers to palliative care referral identified by physicians include misunderstanding the role of the palliative care team,112115116 concerns that a patient may lose hope,112 and institutional culture 115. Physicians perceived patient related barriers to palliative referral as including financial, health literacy, and cultural aspects, the patient’s living situation, and disinclination for home visits 115. Patients’ own perceived barriers to palliative care access cited in order from most to least common were preference for self-management, lack of physician recommendation, misconceptions regarding the role of palliative care, time, and cost barriers 117.…”