Some MCOs have made significant strides in end-of-life care, and they are working to bring this type of care program to patients in need.
Aetna has made end-of-life care planning a core competency among its nurse case managers. These services are available to all Aetna members regardless of whether they have the expanded benefits package included in the Compassionate Care Program.
"We have the opportunity to raise the expectations of our members for improved end-of-life care for themselves or their families," says Judith Black, MD, medical director, senior products for Highmark. Highmark has information on its Web site for members and includes information on end-of-life care and advance directives in its geriatric resources toolkit for physicians. "Our care and case managers, and the nurses who staff Blues On Call, our member education and support service, identify those who might need information to support advance care planning discussions," Dr. Black says. Highmark encourages nursing homes to use the Physician Orders for Life-Sustaining Treatment [POLST] form, a document designed to help honor the treatment wishes of patients at end-of-life. Working with network physicians, Highmark encourages members to identify a healthcare proxy and complete an advance directive, or living will. Designating a healthcare proxy means that that person can make medical decisions if you could no longer make or express your healthcare wishes. The advance directive outlines the types of treatment desired at end-of-life and can help guide discussions with your proxy.
"While we have a variety of care management programs [dealing specifically with the chronically ill with various diseases such as heart or lung failure and diabetes] these care management programs generally are office-based with phone support," says Richard D. Brumley, MD, physician-in-charge, Kaiser Permanente Hospice and Home Health. "We found sicker patients needed more intensive support in the home which we can offer through the palliative care program as we make visits to patients in their residence." Also, some patients want to receive potentially "curative" therapy. For these patients, Dr. Brumley has developed a palliative care program, which is similar to hospice in many ways, but serves chronically ill patients who could benefit from more supportive care in the home. Dr. Brumley and Kaiser colleague Kristine Hillary, MSN, RNP, developed a Web site to help promote home-based palliative care (www.growthhouse.org/palliative). Dr. Brumley believes that the funding source to provide care is important. While hospice care for appropriate patients can be billed to Medicare, palliative care has no specific funding source and must be paid for out of the usual capitated payment a MCO receives to provide healthcare. "Numerous surveys have shown that patients are highly satisfied with hospice care," Dr. Brumley says. "The palliative care program we provide also has demonstrated highly satisfied patients and families."