Portal de Periódicos da CAPES

A Blue Ocean Strategy for Palliative Care: Focus on Family Caregivers

2015; Elsevier BV; Volume: 51; Issue: 3 Linguagem: Inglês

10.1016/j.jpainsymman.2015.12.305

1873-6513

Arif H. Kamal, J. Nicholas Dionne‐Odom,

Patient Dignity and Privacy

In a short 10 years, specialty palliative care has grown exponentially in the U.S., evolving from an inpatient service found in just a few, early-adopter centers to an integrated inpatient and outpatient interdisciplinary care team operating in two-thirds of the 5600 U.S. hospitals.1Center to Advance Palliative Care (CAPC)National Palliative Care Registry 2012 annual survey summary. CAPC, New York2014Google Scholar The Center to Advance Palliative Care estimates that more than six million patients were touched by palliative care in 2014, only a few years removed from the dark cloud of "death panels" that greatly distorted American public perception. In the business world, strategy experts would call palliative care's remarkable growth and penetration high "operational effectiveness." Thus, palliative care has performed better than its competitors to both grow and thrive. Without successes in operational effectiveness, palliative care would still be a niche service, instead of an expected consultation service in all U.S. hospitals. Operational effectiveness, which includes expansion into areas of care typically not sought after by others (e.g., complex psychosocial situations, difficult to manage symptoms, actively dying patients), has been the driver that has interwoven the palliative care "organization" into the fabric of usual health care. Such differentiation of services has temporarily placed palliative care as relevant in the health care landscape. But, the current and past success in operational effectiveness does not elucidate what will keep palliative care outperforming future competitors. Strategies that have earned us success to date are not necessarily strategies that will bring us success in the future. It may be tempting to think that palliative care will never have competitors; however, others are definitely watching its success. It is time to discuss the strategic positioning of palliative care. Strategic positioning, as described by noted economist Dr. Michael Porter, "attempts to achieve sustainable competitive advantage by preserving what is distinctive about an organization, by performing different activities from rivals, or performing similar activities in different ways."2Porter M.E. What is strategy?.Harv Bus Rev. 2006; 6: 61-78Google Scholar In essence, it is reflecting on the long-term vision and focusing efforts on what is done well—and what is done that others do not do. Kim and Mauborgne, in a pivotal Harvard Business Review article and subsequent book, describe a unique type of strategy—a "blue ocean strategy."3Kim W.C. Mauborgne R. Blue ocean strategy.Harv Bus Rev. 2004; 82 (156): 76-84PubMed Google Scholar The blue ocean approach creates uncontested market spaces, not by outcompeting historical competitors. It is about making them irrelevant. Organizations that take a blue ocean strategy think about growth and sustainability outside of the traditional confines and boundaries of the existing industry. A blue ocean strategy is not about stealing customers from others. Rather, it is about creating novel market spaces in areas where competition does not exist. This approach pulls in a brand new group of customers who were traditionally not considered "customers" on the radar screens of the industry. A blue ocean strategy contrasts with a "red ocean," where competitors are in fierce competition over a limited number of customers. The exemplar highlighted by Kim and Mauborgne is of Cirque de Soleil, which invented a new industry by combining the comedic and acrobatic elements of a circus with the dramatic story-telling of the theater. The multimillion dollar success and universally recognized brand of Cirque highlight the benefits of ignoring competitors, leveraging differentiators, focusing on what consumers value—all without necessarily venturing into "distant waters." What might be the "blue ocean strategy" for palliative care? We believe that one such strategy would be intentional and comprehensive support for family caregivers of the seriously ill. We know these individuals well. They are typically spouses, children, and parents who know seriously ill patients intimately and provide them with necessary care and support on a daily basis. From a mission perspective, supporting these family caregivers resonates philosophically with the specialty. Definitions of "palliative care" remind us that the clinical "unit of care" is both patients and their families.4National Quality ForumA national framework and preferred practices for palliative and hospice care quality: A consensus report. National Quality Forum, Washington, DC2006Google Scholar The specialty strives to simultaneously address the distress of those suffering from serious illness and of those individuals who make up their support systems; and emerging evidence suggests that specialty palliative care has the skill to fit this bill.5Dionne-Odom J.N. Azuero A. Lyons K.D. et al.Benefits of early versus delayed palliative care to informal family caregivers of patients with advanced cancer: outcomes from the ENABLE III randomized controlled trial.J Clin Oncol. 2015; 33: 1446-1452Crossref PubMed Scopus (296) Google Scholar From a public health perspective, the justification for supporting family caregivers is not just strong, it is critical. In 2015,6National Alliance for Caregiving and AARP Public Policy Institute. Caregiving in the U.S. Washington DC, 2015. Available at http://www.aarp.org/ppi/info-2015/caregiving-in-the-united-states-2015.html. Accessed November 1, 2015.Google Scholar 34.2 million individuals (or 14.3% of the U.S. population) provided unpaid care to an adult age 50 years or older. Another 10.2 million cared for children age 18 years and younger with a medical or behavioral condition. As expressed eloquently by Former First Lady Rosalynn Carter, "There are four kinds of people in this world—those who have been caregivers, those who currently are caregivers, those who will be caregivers and those who need caregivers." Caregivers not only perform routine tasks formerly carried out by their care recipient (e.g., preparing meals, housework, transportation, lawn maintenance), they also provide 80% of the home health care. They administer medications; track and manage symptoms; assist with activities of daily living; promote patient's self-care; provide psychosocial and spiritual support; partner in patients' health care decisions and serve as proxies at end of life; coordinate medical appointments; and attend to health care financial and legal matters. Caregivers can spend over 40 hours per week performing these tasks, especially in the last year and months of life. Simply put, family caregivers are an absolutely essential component of high-quality health care delivery. From an economic perspective, simply replacing the unpaid service of family caregivers with paid professionals is not a real option. First, there are not enough health care professionals to serve the current health care demands of our country, a trend which is expected to worsen. Second, it would be fiscally starry-eyed to replace family caregiving services with paid professionals given that the price tag has been estimated at $642 billion (which, as a point of comparison, far exceeds the entire 2015 Medicare budget).7Chari A.V. Engberg J. Ray K.N. Mehrotra A. The opportunity costs of informal elder-care in the United States: new estimates from the American Time Use Survey.Health Serv Res. 2015; 50: 871-882Crossref PubMed Scopus (167) Google Scholar If the care delivered by family caregivers were to suddenly vanish, not only would our health care system buckle, our entire economy might collapse. The Institute of Medicine8Institute of MedicineDying in America: Improving quality and honoring individual preferences near the end of life. National Academies Press, Washington DC2014Google Scholar report Dying in America noted that unmet family caregiver needs result in poor physical and mental health and negatively impact their ability to provide care. Moreover, these family caregivers are often not prepared to be proxies9Shalowitz D.I. Garrett-Mayer E. Wendler D. The accuracy of surrogate decision makers: a systematic review.Arch Intern Med. 2006; 166: 493-497Crossref PubMed Scopus (730) Google Scholar and experience negative aftereffects after patients die.10Wendler D. Rid A. Systematic review: the effect on surrogates of making treatment decisions for others.Ann Intern Med. 2011; 154: 336-346Crossref PubMed Scopus (444) Google Scholar Thus, there is an undeniable societal need (or high consumer value) for some entity to ensure that family caregivers stay healthy—not only so they can provide the best care possible to patients, but also for their own sake. We believe palliative care should rise to meet this societal need and take on family caregivers as a new focus of its specialized care. This goes beyond merely re-emphasizing the codified focus on the patient-family unit of care but transcends the traditional paradigm to envision caregivers as a population with needs unto themselves that are created by the labor and service they provide to patients. This requires developing models of care where caregivers receive individualized, focused palliative care assessments, management, and follow-up. As palliative care looks toward another successful decade of service growth and deepened cultural understanding and acceptance of its mission, we believe that family caregivers could be palliative care's blue ocean strategy. Dr. Kamal has research funding from the Agency for Healthcare Research and Quality (K08 HS023681-A1) and Cambia Health Foundation (Sojourns Scholar Award). Dr. J. Nicholas Dionne-Odom is a postdoctoral fellow supported by a National Palliative Care Research Center Career Development Award and by the MSM/TU/UAB Comprehensive Cancer Center Partnership (U54CA118948). The authors have no conflicts of interest to disclose.