Table 1.

Policies to promote palliative care for patients with ESRD

Policy	Barrier Addressed	Stakeholders	Examples of Implementation
Universal screening for palliative care needs	Access	Nephrologists, dialysis providers, insurers, clinical organizations	Screen patients with the surprise question at dialysis initiation and at hospital admissions
			Standardized symptom assessments and treatment algorithms for pain, depression, and sleep disorders
Incorporate palliative care measures in the ESRD QIP	Access	Nephrologists, dialysis providers, CMMS	Documentation of the advance care plan or surrogate decision maker in the medical record
Train the nephrology workforce to deliver palliative care	Capacity	Fellowship programs, accreditation organizations, professional societies	Enhance palliative care content and assess competencies in nephrology fellowship curriculum
			Emphasize palliative care training for dialysis nurses, social workers, and pharmacists
Payment reforms for palliative care services	Capacity	CMMS	Shared-savings model (i.e., including non-ESRD services in the “bundle”)
			Concurrent dialysis and hospice care
			Reimbursement for time-intensive services such as advance care planning
Fund palliative care research	Evidence base	Funding agencies, professional societies	Joint NIH/CMMS/VA funding of high-priority palliative care trials
			Dedicated funding streams for junior and midcareer palliative care researchers
			Multi-institution ESRD palliative care research collaboratives

QIP, Quality Incentive Program; CMMS, Centers for Medicare and Medicaid Services; NIH, National Institutes of Health; VA, Veterans Affairs.