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Innovation Closes Care Gaps for Critically Ill Patients


Community-based palliative care in the patient’s home improves care quality as well as increases satisfaction with the healthcare experience.

Patient and Doctor

When the venerable Kaiser Foundation Health Plan recently unveiled a Food for Life program, it set an aggressive pace for payers to account for Social Determinants of Health (SDoH), such as food insecurity. The Kaiser program, a multi-pronged social needs initiative set to launch in 2020, is designed to increase healthy food supplies for Kaiser Permanente members by connecting them with underutilized resources. Kaiser recognizes that food deficits are a significant barrier to health, because when people are hungry, lack proper nutrition, or have limited access to the right types of food, medical conditions arise or deteriorate, resulting in avoidable medicalization. 

Identifying members burdened by social and economic challenges has become highly important to achieving optimal member care coordination. In fact, CMS now allows Medicare Advantage and Part D plans to offer supplemental benefits to specifically address SDoH issues.

This increased awareness has prompted health plans and at-risk provider entities, like accountable care organizations or delegated medical groups, to address SDoH and the myriad of non-clinical issues facing members, regardless of their socioeconomic status. Along with focused attention to clinical matters, they are now beginning to understand that these non-clinical concerns, such as food insecurities, transportation challenges, housing problems and even social isolation, are magnified exponentially for individuals and their caregivers facing serious illness and living at home.

Even the most mundane, non-clinical household problems or unexpected events associated with daily living can be overwhelming for these vulnerable patients and their families. Left unattended, these non-clinical issues can create critical gaps in care that often compromise the overall healthcare experience and give rise to unplanned care, overmedicalization and higher costs. These results highlight the need for payers to provide seriously ill members with greater home-based support and increased attention to care coordination that accounts for SDoH and non-clinical problems.

These examples illustrate what can happen when seemingly small challenges snowball into a catastrophic health-related event, resulting in suboptimal outcomes and  significant healthcare expenditures:  a non-working refrigerator can lead to a plan member with advanced diabetes being non-adherent with insulin because there is no place to store it, resulting in complex health problems and high ER utilization; a member who may feel isolated and alone falls into depression, which can impact overall health and increased suicide rates; or a member without a car may not be able to get to physician appointments, medications, and other necessities, which will result in ED visits.

Related: Pharma’s Role In Addressing Social Determinants Of Health

Importance of community-based palliative care for effective care coordination

Traditionally, discussions around care coordination referred to the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of healthcare services. As care needs become more complex, the number of potential participants and relationships among participants tends to increase.
Care coordination for home-bound seriously ill members is increasingly taking on new dimensions that account for the frequently overlooked non-clinical issues and SDoH as referenced above. As the market shifts toward value-based care, payers and treating physicians are beginning to understand the importance of recognizing and resolving these issues whenever possible. Many are adopting community-based palliative care (CBPC) provided in the member’s home, since it not only improves care quality and care coordination, but also increases member engagement and enhances their satisfaction with the healthcare experience.    

CBPC is a field that seeks to integrate palliative and serious illness care with established local community resources. It is making a substantial difference in providing quality care and closing gaps in care for seriously ill members living at home.  A population health-centric model of CBPC takes this approach to an even more sophisticated and dynamic level: using predictive analytics to identify members earlier in the disease trajectory and predicting who is likely to experience an over-medicalized or inappropriate death; integrating structure and process to programs, services and in-home assessments; and deploying dedicated clinician teams-including specially trained nurses and social workers-to engage with members and caregivers in their homes.
These dedicated teams focus on resolving clinical, non-clinical and SDoH issues, creating opportunities for better collection of relevant information and coordination of resources and accompanied by improved care quality and enhanced member engagement. Payers that incorporate specialized CBPC into their case management programs effectively close gaps in care, relieve suffering, and improve quality of life for people of any age and at any stage-whether their illness is curable, chronic, or life-threatening.
These payers also demonstrate success at lowering emergency department utilization and preventable readmissions, as highlighted in a peer-reviewed study published in the April 2019 issue of the Journal of Palliative Medicine. The study demonstrated the positive outcomes of a systemized, structured and evidence-based care management program that resulted in more compassionate, affordable and sustainable high-quality care, reduced utilization and lower medical costs.

This validates how CBPC teams further enhance care coordination for vulnerable individuals facing serious illness and help to scale constrained medical and care management resources by providing needed insights and visibility into how the member and caregiver are managing at home.

They can quickly resolve problematic issues-like arranging to replace a broken refrigerator by coordinating with the patient’s caregiver and religious leaders; finding a neighbor who can drive a member to a community day care to relieve loneliness; or arranging to have prescriptions delivered directly to the home for members who don’t have transportation. Such quick and efficient resolutions not only result in a better health outcome, but also significantly reduce costs related to caring for these members.

Specialized CBPC: Scalable, process-driven, and systemized
For payers, one of the most important aspects of this process-driven, systemized CBPC approach is a consistent, structured way to scale the solution across member populations and diverse geographies. Additional success factors include:

1.  Sophisticated predictive analytics for patient identification.
Predictive models use artificial intelligence (AI) and natural machine learning (NML) to identify members who would benefit from palliative care in a timely way. When used in combination with real time referrals from health plan case managers or others, this helps to identify members earlier in the disease trajectory and determine who is most likely to experience an over-medicalized or inappropriate death. Predictive analytics used for real-time identification goes beyond the limitations of a 90-day claims lag, while real-time referrals alone fail to scale and identify for optimal benefit.

2.  Local palliative care teams to increase the reach and frequency of member engagement.
Once the member has been identified, the best specialized CBPC programs offer highly trained care teams comprised largely of nurses and social workers, leveraging resources that already exist in the community. This approach serves not only as an extension of the physician, but just as importantly, the payer’s case management team. These dedicated teams use structured palliative assessments and interventions to evaluate and manage gaps in care, support care coordination and address SDoH. This includes issues related to disease exacerbation, unmanaged symptoms, access to care, health literacy, food scarcity, neighborhood safety, social supports, and family/caregiver issues.

Specialized CBPC programs help case managers to be more efficient and effective, sharing with them a member’s completed palliative assessments and care plans following calls or home visits.

3.  Standardized platform with embedded risk-based care paths and palliative assessments to guide, track and measure patient and caregiver interactions.
An optimized, process-driven, and structured CBPC approach identifies and engages members while capturing encounter data. The resultant robust suite of reports provides important actionable information about the population served, clinical outcomes, enrollment and disenrollment metrics and other highly relevant data points. This capability further extends the support of the existing case management team and instructs and guides its affiliated CBPC partners in member engagement. Such a program is designed to identify and address the medical, physical, psychosocial and spiritual needs of patients/members/caregivers and is guided by scientifically validated palliative assessments.

Importance of ongoing assessments

Throughout the assessment process and using motivational interviewing and key assessment questions, specialized CBPC clinicians continually assess the impact of significant factors influencing end-of-life decision-making. Some advanced CBPC solutions provide an evidence-based and systematic evaluation to foster continued improvements in the delivery of high-quality palliative care services to members/patients and caregivers. By identifying patients’ and caregivers’ priority needs, this palliative evaluation guides clinicians in terms of making a timely selection of appropriate evidence-based interventions and assessing the effectiveness of intervention over time.

Answers payer need for patient-centric care

A specialized CBPC solution places the member at the center of a highly structured care process. The convergence of care coordination, member/physician engagement, medical home extension and focus on SDoH results in a more compassionate, affordable and sustainable level of care. Collectively, these activities support advance care planning, avoid unplanned care, reduce over-medicalization and help case managers establish a more robust relationship with members.   

When a process-driven, systemized approach to specialized CBPC is used to close both clinical and non-clinical gaps in care, payers make real progress in bringing a specialized palliative care solution to members across the enterprise. The positive impact upon quality improvement, member satisfaction and over-medicalization can be measured, with progress benchmarks achieved daily and over time.  


Greer Myers is president at Turn-Key Health, an Enclara Healthcare company, serving health plans, provider organizations and their members who experience a serious or advanced illness, located in Philadelphia. 

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