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Five strategies to improve care for members with advanced disease


Here are five key strategies to improve care and outcomes for members with advanced illness.


Serious illness is becoming serious business for our nation’s healthcare payers.

By 2030, an estimated 72 million Americans will be aged 65 years or older, nearly one-fifth of the U.S. population, according to U.S. News and World Report.  Unfortunately, approximately 92% of older adults have at least one chronic disease, and 77% have at least two, with chronic diseases accounting for 75% of the money our nation spends on healthcare, according to the National Council on Aging.  Mean capita spending in the last year of life in the U.S. is high, reaching $80,000, with hospital spending accounting for much of these costs (44.2%), despite peoples’ desire to reduce burden on families, avoid futile care, and die at home, according to Health Affairs.

Given the enormity of the socioeconomic burdens associated with serious illness, and the fact these are the sickest and most fragile members of a health plan, managed care decision-makers are seeking proven strategies to deliver excellent care and improve quality of life for these individuals, at lower total cost.

Below are key strategies to improve care and outcomes for members with advanced illness:

Strategy 1.  Utilize a specialized population health management (PHM) solution.

There are two important components for a successful PHM solution: sophisticated predictive analytics and capabilities to deploy a clinically driven approach:

First, Sophisticated predictive analytics can identify members with advanced illness well before they experience a costly over-medicalized or inappropriate death. For example, some companies now offer highly specialized predictive analytics and proprietary algorithms that use historical data to proactively identify members who will benefit most from specialized case management and home-based palliative care.  

Too often, a generalist population health approach lacks specificity with unrefined analytics that simply track the member’s disease process rather than placing a specialty focus on advanced illness and end-of-life as they relate to the individual’s goals of care. The majority of current solutions miss the mark when it comes to forecasting what will actually happen to the patient, and fall woefully short in transitioning from disease or event-specific care management to a patient-centered approach that addresses individual needs. 

Rather than simply tracking disease progression, the optimal analytic model will project future medical events so that care management resources are targeted appropriately. Some predictive models are capable of forecasting which of their members with advanced illness are more likely to experience avoidable hospitalizations, readmissions, ICU days or other interventions in the next six to 12 months.

Combining these data driven approaches with referrals from case managers, discharge planners, and others, improves the ability to identify those who would benefit from specialized services compared to relying on referrals from clinicians alone.   

Second, the other critical PHM success factor is developing and deploying a clinically-driven approach such as a specialized palliative care program designed specifically for this fragile population.

Without the proper care management infrastructure, appropriate staffing, and resources to intervene when something is predicted to happen, the potential of improving care outcomes for members identified through data will fall short. To achieve goals, data analytics must be combined with best practices supported by evidence, clinical protocols and patient outcomes-which lead us to the next strategy.

Strategy 2.  Introduce a specialized palliative care program.

Based upon timely and accurate identification of members with advanced illness, payers can introduce a specialized palliative care program that engages with patients and caregivers to provide: relief from symptoms and stress, medication management, care coordination and other support that are frequently missing from traditional care. 

As palliative care evolves from an end-of-life modality to a PHM strategy, a growing number of payers are introducing these specialized services. Introduction of palliative care earlier increases the likelihood of improving quality of life while avoiding burdensome hospitalizations, skilled nursing stays and treatments that frequently result in more suffering without meaningful life prolongation.

In fact, a study in the New England Journal of Medicine shows palliative care can also help patients live longer.  In a study of 151 patients with advanced lung cancer, those given early, concurrent palliative care survived 11.6 months, nearly three months longer than those who received standard medical care. Evidence also shows that, with or without curative treatments, a palliative approach offers the best chance of maintaining the highest possible quality of life for the longest possible time, according to the National Center for Biotechnology Information.

Next: Strategy #3



Strategy 3.  Implement a community-based, in-home care program.

By deploying community-based palliative care teams comprised of specially trained nurses and clinical social workers, payers take one of the most productive steps to providing a beneficial service among their most vulnerable and needy members.  

The palliative nurses and social workers make home visits, offering a highly pro-active, additional layer of support to address the physical, emotional and social needs of patients and families experiencing the burdens of advanced illness. Services provided by these interdisciplinary teams are guided by in-home and telephonic assessments that include symptom management, medication review, addressing gaps in care, establishing goals of care, and developing a palliative care plan in conjunction with the treating physician and health plan case manager.

Experience shows that social workers and nurses with palliative expertise are particularly experienced and adept at conducting sensitive, meaningful conversations among patients, families and caregivers. This results in shared decision-making that advances a clear understanding of what members and families view as important at the end-of-life, and matches treatments to informed goals of care. This helps to avert costly, often unwanted interventions of questionable benefit, and frequently leads to earlier adoption of hospice so that the member can remain in their home.

What’s more, payers can now turn to emerging companies that will convene the right palliative care clinical resources and provide them with appropriate training, support and oversight. This allows payers to match these resources to the specific needs of the patient, increase the scope and frequency of touching individual patient lives and scale their programs for larger populations.

The extraordinary level of personalized support provided by palliative clinicians results in a more patient-centered approach to care and ensures more seamless transitions to achieve safer, more effective care.

Members who are experiencing serious or advanced illness benefit from the emotional and spiritual support and improved care coordination provided by the care team. Cost savings and reduced member copays are a by-product of improving care coordination and reducing unwanted and unnecessary hospital utilization. At the same time, patients and family caregivers are more satisfied not only with the care received, but also with their health plan participation.

Payers sometimes ask why physicians can’t fill this role. The answer is that while some physicians are trained in palliative care and capable of conducting sensitive conversations regarding goals of care, they are few and far between-and may become even scarcer given proposed budget cuts to training programs. And few of them have the time necessary to offer this intense level of ongoing discussions with patients and families.

Strategy 4.  Relieve caregiver burdens.

There are 40.4 million unpaid caregivers of adults aged 65 years and older in the United States. Of that group, nine-in-10 are providing care for an aging relative, and a plurality is caring for a parent, according to data from the Bureau of Labor Statistics.  While caregivers are an important part of the care team in an increasingly patient-centric environment, there is insufficient training and support for this shift of medical care to the family caregiver, further eroding their earning potential and harming their health. In many cases, caregivers have had no training to perform these tasks and have had to learn on their own, according a report released by the AARP and United Hospital Fund.

This is precisely where palliative trained nurses and social workers demonstrate their value and help to relieve family members of the burdens of caring for a loved one. Caregivers remain dedicated to the patient, but appreciate assistance with referrals to community services and other resources, and value the regular outreach and home visits. During the last year of an ill person’s life, family caregivers spend an average of 24.4 hours per week providing care, according to the Family Caregiver Alliance, with increasingly expanded roles and responsibilities in caring for those with advanced illness.

Being a caregiver brings with it significant financial issues, with the pressures of long-term caregiving carrying even more severe consequences, especially for women.  Informal caregivers personally lose about $659,139 over a lifetime: $25,494 in Social Security benefits; $67,202 in pension benefits; and $566,443 in forgone wages, according to the Family Caregiver Alliance.  

Unpaid caregivers who assist in daily activities often exhibit extraordinary commitment, provide enormous value and face significant personal and financial burdens in this role. While many family members readily assume this responsibility, the work takes a toll, especially when they must administer medications, maintain complex equipment, and perform the physical labor of feeding, preparing special diets, bathing, toileting, changing and cleaning, dressing, turning and transporting a family member, according to the National Center for Biotechnology Information. Palliative care clinicians view both the patient and family as the focus of care and attend to their needs accordingly.

Next: Strategy 5



Strategy 5. Remaining at home enhances member satisfaction with care and plan participation.

The goal of palliative care is to avoid burdensome pain, symptoms and hospitalization.

Clinicians and researchers widely acknowledge the importance of addressing not only physical pain and suffering, but also the need to attend to highly emotional and spiritual anxieties. As referenced earlier, community-based palliative care and discussions directed by palliative nurses and social workers gives individuals an opportunity to influence decisions about their care and a voice in choosing to remain at home, according to the Dartmouth Atlas of Healthcare.

The need for this level of care is underscored in one study of bereaved family members following the death of a loved one who died in a hospital or a nursing home. They reported high rates of unmet needs for symptom management, concerns with physician communication about medical decision-making, a lack of emotional support for themselves, and a belief that their dying family member was not always treated with respect.

In contrast, bereaved family members of patients with community-based palliative care services vs. other settings of care reported higher satisfaction, fewer concerns with care, and fewer unmet needs, according to the Stanford School of Medicine.  Studies show that approximately 80% of Americans would prefer to die at home, if possible, and yet only 20% achieve that wish.

Palliative care: Good for members, health plans 

When quality of life for members with advanced illness is emphasized over quantity of treatment, managed care decision-makers move closer to achieving the Triple Aim.

Common sense tells us that people with advanced illness do not appreciate going in and out of hospitals, or cycling from hospital, to skilled nursing centers, to home. 

As a nation, lack of attention to the special needs of those with advanced illness is becoming a massive problem that costs our healthcare system billions of dollars. For health payers, these challenges weigh heavily on resources, a situation that has galvanized leaders to search for solutions.

Community-based palliative care may be one of the most viable opportunities to call off the search and begin the healing.



Terri Maxwell, PhD, APRN, is chief clinical officer at Turn-Key Health.




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