Insights Into Service Line Strategic Planning: Palliative Medicine’s Expanding scope is an identity Question
Most service-line strategic planning starts with capacity: how many patients, how many FTEs, and how much revenue. For palliative medicine right now, the more urgent question sits upstream of all of that — what is the program's actual purpose, and is it still the purpose the program was built around?
Two recent developments are pulling at the boundaries of what palliative medicine covers. Neither is dramatic alone. Together they force a service line to answer a question that is easy to defer indefinitely: are we the team that manages symptoms and goals-of-care conversations near the end of life, or are we becoming something broader — and if so, how much broader, and what should the structure look like?
A strategic-planning question
Strategic planning is often treated as an every-few-years capacity exercise. The scope pressures below are the argument for why it has to be routine. Scope drifts continuously — through referral patterns, individual clinician interests, and gaps elsewhere in the system — while formal planning happens episodically. The gap between those two clocks is where a service line could lose control of its own identity. Two current, real-world examples show how fast that gap opens.
Example 1: Deprescribing is being named as a competency
A review published in late July 2026 in the Journal of Hospice & Palliative Nursing examined deprescribing — systematically stopping medications whose risks now outweigh their benefit — as a distinct, nursing-led competency in hospice and palliative care.
This is not new work; teams already do it informally. What is new is the move to name it as a competency. A skill a clinician happens to have is a personal strength. A named, trainable, certifiable competency is a service-line commitment — something the program can be staffed for, evaluated on, and held accountable to. That reclassification is exactly what strategic planning must reckon with.
Example 2: Mental health integration is being formalized as core scope
A parallel body of work — a national clinician survey, a Delphi study defining primary mental-health competencies for hospice and palliative medicine physicians, and research on hospice's role in prolonged grief disorder — is pushing to treat mental health care as core palliative scope rather than something referred out to psychiatry.
The demand side reinforces this from the opposite direction. When a hospital lacks adequate psychiatry access (increasingly common) palliative care gets consulted for delirium, refractory anxiety, and grief-related crises not because the literature says it should, but because no one else is available. A recent Mount Sinai scope-of-practice guideline addressed this directly, recommending that programs track "non-eligible" referrals to surface the unmet system needs palliative care is informally absorbing. A program that does not track these referrals cannot distinguish scope it has chosen from scope it has absorbed by default.
The three positioning choices a service line has
When a competency like deprescribing or mental health integration starts getting formalized, a palliative program has roughly three strategic postures available. Staying passive is in itself a choice with consequences.
Absorb it as core scope. Build formal training, staffing, and workflow around the new competency, treating it the way the field already treats symptom management and goals-of-care conversations. This is the highest-investment option: it usually means dedicated training time, potentially new hires, and a service line willing to be evaluated on outcomes in that domain.
Formalize a partnership instead of building internally. Rather than absorbing deprescribing pharmacology or mental health treatment directly, build a tight, protocolized referral or co-management relationship with pharmacy or psychiatry, with palliative care coordinating rather than delivering. Lower investment, but it requires those partner departments to have capacity — which is not guaranteed.
Hold the current boundary deliberately. Continue treating these as adjacent skills individual clinicians may pick up, without formalizing training or staffing around them. This is a legitimate strategic choice — not a failure to keep up — provided it's made consciously and communicated clearly to referring teams, rather than happening by default because no one revisited the service line's scope statement.
The point isn't that one of these is correct. It's that a service line that hasn't explicitly chosen one of the three is being defined by whichever individual clinicians happen to be interested in deprescribing or mental health. And critically, these two competencies don't have to get the same answer. Deprescribing and mental health pull in different strategic directions and treating them separately reveals something important about the framework itself.
Deprescribing is the natural "partner" candidate. The evidence base for pharmacist-led deprescribing in palliative care is now substantial enough that partnership may actually be the superior model, not just the cheaper one. Across multiple studies, palliative care pharmacists achieve 71–82% implementation rates for deprescribing recommendations with no observed short-term clinical harm. In a hospice-specific pilot, 79% of patients achieved at least 50% reduction in use of medications flagged for deprescribing, with each additional pharmacist encounter associated with significantly higher odds of success. The AHA's July 2026 scientific statement on deprescribing in cardiovascular polypharmacy explicitly endorses team-based approaches leveraging pharmacists and nurses rather than physician-directed deprescribing alone. This is a case where the evidence suggests partnership may produce better outcomes because pharmacists bring medication-specific expertise that palliative clinicians typically don't match.
Mental Health integration is the harder call and benefits from a more granular decision than a single posture. The Delphi study the field is working from produced 32 competencies — but the national clinician survey that accompanies it found that while palliative care clinicians felt comfortable managing mood, anxiety, and neurocognitive disorders, comfort dropped substantially for other psychiatric comorbidities, and 80% reported that patients' mental health status impacted their comfort delivering general palliative care. A parallel UK study of hospice staff found that while 72% were willing to explore difficult psychological content, only 25% strongly agreed they could differentiate level of psychological need. The practical implication: basic mental health screening and management is absorbable. Moderate-to-complex psychiatric comorbidity is not — and "partner" for that tier means actual embedded psychology or psychiatry time, not just a referral pathway.
The NCP guidelines are an anchor worth naming
The identity question has an institutional anchor that's worth naming. The National Consensus Project's Clinical Practice Guidelines already define eight domains of quality palliative care, and, for example, Domain 3 — psychological and psychiatric aspects — explicitly states that the interdisciplinary team "systematically addresses psychological and psychiatric aspects of care." The identity question raised by asking the questions above is partly a question about whether the NCP framework is aspirational or operational — whether programs are staffed and structured to deliver all eight domains, or whether some domains are nominally claimed but practically outsourced or omitted. Being honest about that gap is a prerequisite for any useful strategic conversation.
The workforce pipeline is a constraint
An early-August 2026 project in the Journal of Hospice & Palliative Nursing built palliative-competency case scenarios for undergraduate nursing students after finding that new graduates consistently feel unprepared for the pharmacological and ethical complexity of pain management once they reach the floor. That's worth reading as more than an education story.
The broader workforce picture is stark. Palliative nursing education was not formally integrated into U.S. nursing curricula until 2021. Only about a dozen healthcare organizations offer specialty palliative nurse residency or fellowship programs. For APRNs, fewer than a dozen fellowship programs exist nationally; each training one to three fellows, often built on medical rather than nursing curricula without equivalent support infrastructure. On the physician side, workforce modeling projects a "workforce valley" — declining HPM physician numbers that won't recover to current levels until 2045 absent policy change, with a projected physician-to-seriously-ill-person ratio of roughly 1:28,000 by 2030.
This reframes the identity question. Every "absorb" decision has to be tested against this constraint before it goes forward.
Questions a service line should be asking in its own strategic planning
Who are we today, precisely? Not the mission-statement version — the actual, current, unwritten scope. Which of these adjacent competencies individual clinicians already handling informally? How many of our consults are for needs that technically fall outside our defined scope? And how much of that work is invisible to the rest of the organization?
Which of the three postures fits our current capacity and referral base — for each competency separately? Deprescribing and mental health don't have to get the same answer and probably shouldn't.
If we absorb a competency, what does it cost — and can our pipeline deliver it? Training time, potential new roles, credentialing, and the honest question of whether incoming graduates can actually perform the work the service line is committing to.
What are we implicitly asking primary teams to handle? Does our current training investment in primary care, hospitalists, and specialists match that ask, or are we assuming primary palliative capacity that doesn't exist yet?
Is the work we're absorbing by default — through referral patterns — work we would choose if we were deciding on purpose? Track non-eligible referrals. The answer is often no, and naming that creates leverage for the system-level or service line conversation about where those needs may be better served.
Can we bill for what we're expanding into? If a new competency adds clinical time that existing codes don't capture, the sustainability question is real and should be answered before the “scope” question.
None of these questions have a universally correct answer. They're meant to convert "the literature is expanding palliative medicine's scope" from something that happens to a service line into something a service line decides, deliberately, as part of its next strategic planning cycle.
The Vantage Clinical Partners Perspective
Working through an identity question like this one is exactly the kind of engagement Vantage Clinical Partners is built around.
Vantage's approach to palliative medicine service-line strategy starts from the same place this piece does: before deciding what to build next, get an honest, current picture of what the service actually is today. That current-state assessment — evaluating scope, sites of service, referral sources, and quality outcomes — is the operational answer to the first question above: who are we today, precisely?
From there, Vantage helps build a roadmap across the full continuum of care for people living with serious illness: pre-hospitalization touchpoints, home-based palliative medicine, ambulatory clinic-based care, and structured relationships with hospice organizations. That roadmap work is the direct operational counterpart to the absorb/partner/hold framework — it turns a scope decision into an actual plan for where and how care gets delivered across settings.
Because scope decisions are ultimately workforce decisions, Vantage's work extends into practice operations, leadership design, compensation alignment, clinician wellbeing, and the value metrics that keep a service line's chosen identity connected to how the rest of the health system measures success.
For a palliative program working through the questions raised in this piece, that combination — current-state honesty, continuum-of-care planning, and workforce sustainability — is a structured way to run the identity exercise this article is arguing every program needs.
Beth Papetti, MBA FHM
Principal & Chief Operating Officer
References
Deprescribing in hospice and palliative care: a rapid review. Journal of Hospice & Palliative Nursing, July 27, 2026.
Undergraduate nursing students struggle with understanding pharmacological pain management, especially in palliative care. Journal of Hospice & Palliative Nursing, August 6, 2026.
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