Home-Based Palliative Care Improves Outcomes for Individuals Struggling with Serious Illness: Addresses SDoH, Customizes Care for Dual Eligible Members

Published October 21, 2020

We are pleased to share insights and guidance presented during a recent webinar, “Home-Based Palliative Care: Better Outcomes for Seriously Ill Patients,” hosted by America’s Health Insurance Plans (AHIP).

During the webinar, Jasen Gundersen, M.D., MBA, chief medical Officer, CareCentrix, Say Salomon, M.D., National Medical director of Acute and Post-Acute Care, ChenMed, and David J. Sand, M.D., MBA, FACS, chief medical officer, Care N’ Care Insurance Company, Inc. extolled the many benefits of the home-based palliative care (HBPC) solutions provided by Turn-Key Health, a leading home-based palliative care company. Turn-Key Health, a CareCentrix company, serves health plans, hospitals and physicians.

The purpose of the conversation was to understand the value of home-based palliative care, recognize opportunities for HBPC clinicians to improve disease management and affect the outcomes for those who are seriously ill. The speakers highlighted Turn-Key Health’s role in helping to identify patients through claims data by using a predictive algorithm that assigns a risk score.

Building a better model for care at home for people with serious illness requires HBPC to improve outcomes and enhance quality of life. When payors provide this level of care and support for dual eligible members (Medicare/Medicaid) and their caregivers, they can more effectively address social determinants of health (SDoH), integrate care management and apply artificial intelligence / predictive analytics to identify individual needs.

HBPC clinicians develop trusting relationships with seriously ill patients through telehealth and home-based support that includes symptom management, medication reconciliation, psychosocial/spiritual support, and documentation of advance care plans, care coordination and mobilizing community resources. Scalable HBPC solutions can also improve provider, patient and caregiver satisfaction.

Optimal HBPC programs include specially trained palliative care teams that assess the needs of the “whole patient” and their caregivers, and provide support that aligns care with their goals.

COVID-19 Impact on Care in the Home

The COVID-19 pandemic has reinforced the benefits of providing HBPC in addition to the services offered under the umbrella of the traditional health care system. With today’s technological capabilities, the surging adoption of telehealth and remote monitoring in response to pandemic lockdowns and social distancing, and with much-needed changes to ease regulatory restrictions governing telehealth access, the door is now open for HBPC.

Bridging Gap between Physicians and Patients

Turn-Key Health’s predictive analytic risk scoring is based upon healthcare utilization and a number of other metrics related to comorbidities, as well as pharmacy and lab data, giving physicians objective information based on historical data to identify candidates for the program. A palliative clinician outreaches to identify members to invite them to enroll.

This approach brings expertise in integrating the HBPC program with the physician community, doing much of the work upfront and white labelling some of the services. They work proactively to engage physicians in the program, ensuring that they do not feel disintermediated by the process and are maintained as the patient’s primary care provider.

How HBPC Collaboration Works

The panel also noted the importance of empowering physicians with primary palliative care skills, including conducting goals-of-care discussions with the patient/caregiver and providing basic symptom management. Once they have gained these initial skills, an HBPC specialist can provide follow-up services.

While the physician oversees the more complex cases in terms of symptom management and psychosocial issues, collaborating with an HBPC solution means the primary care physician receives a call from the palliative care team to discuss, for example, changing medications or requesting DME so that the primary care physician is directly coordinating care.

The patient and their caregiver are informed every step of the way. Information from assessments shared with the health plan case managers and ChenMed primary care physician make this a true partnership that primary care physicians and health plans can embrace.

Patient Engagement

The speakers focused on a high-touch HBPC model that addresses goals of care and transition of care across the patient journey in a way that gains patient trust from the outset as a natural aspect of long-term planning. Once the patient feels engaged and understood by the care team, they are better equipped to have a conversation about end-of-life preferences.

The HBPC team involves the primary care provider in advance care planning as a way of enhancing the patient/physician relationship, strengthening the provider’s ability to have these sensitive talks. This allows the HBPC team to continue these discussions and keeps the primary care physicians and care management team in the loop.

Much Needed Shift in Care

The speakers stated that when it comes to putting together a HBPC program, it is important to focus on scalability so that it can affect more patients. They also discussed the value of Turn-Key Health’s algorithm for identifying a significant number of patients who are at risk of over medicalization during their final months of life. Other critical factors to look for are 1) the ability to get the program up and running with specially trained HBPC nurses and social workers and 2) getting physician buy-in early on.

Speakers also defined the difference between palliative care and hospice. Both involve holistic care for patients with advanced illness to improve quality of life. Hospice is primarily supported by the Hospice Medicare Benefit and has specific criteria for admission based upon a prognosis of six months or less and the patient opts to no longer pursue treatment for the illness.

Palliative care is provided to patients with serious or advanced illness without regard to prognosis and is provided concurrently with active treatment. The group agreed that a key factor is to engage with and educate physicians about these differences because, for many providers, the two are indistinguishable. When physicians gain a greater understanding and appreciation for HBPC, their patients will benefit. As part of this collaborative process, primary care physicians and other health care providers can see how Turn-Key Health’s approach helps to enhance continuity of care and care coordination.

Turn-Key Health does much of this legwork up front, highlighting the difference between palliative and hospice care, delivering letters to each enrolled member’s health care provider about how they are engaging a patient into the HBPC process and getting provider buy-in very early in the process. All of this goes a long way in making the physician feel like an integral part of the care delivered in the patient’s home.

The webinar concluded on the point that, despite the tragedy and hardships, the COVID-19 pandemic has sparked vital discussion about how to expand care beyond hospital walls in a way that enhances care, improves outcomes and leads to a better quality of life for the seriously ill.