Unlock the Value of Community-Based Palliative Care to Close … · 2019-10-28 · Clearly, these challenges require better support for physicians to provide high quality, patient-centered

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How A Broken RefrigeratorLed To HigherHealth Care Costs

Unlock the Value of Community-Based Palliative

Care to Close Clinical and Non-Clinical Care Gaps

© 2019 Turn-Key Health

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When a serious or advanced illness devastates a person’s health and well-being, even the most mundane tasks can become insurmountable for members and caregivers. For example, consider the difficulties facing Claire, an 84-year-old woman with advanced diabetes who lived at home, was non-adherent with her insulin and frequently visited her local emergency department. As it turned out, the real culprit of her medication non-compliance was a broken refrigerator so she could not properly store her insulin. It’s this type of non-clinical issue that confounds not only the patient, but also the payer and her physician.

This example exemplifies the need for a care coordination plan that accounts for both clinical and non-clinical issues. This specialized approach to care coordination would likely have identified a non-working refrigerator as not only problematic for insulin storage, but also for ensuring that her food supply stayed fresh.

Traditionally, discussions around care coordination refer to issues related to clinical care - direct diagnosis, treatment or testing, and reporting and documenting care back to the medical home. However, there is growing recognition among health care providers and payers of the need to address the often-overlooked non-clinical issues and social determinants of health (SDoH) that can impact care quality. This ranges from something as unexpected as a broken refrigerator to other issues, such as food insecurity, low health literacy or the need for transportation - which often impedes the ability to travel to the pharmacy to fill a prescription or attend physician appointments.

Left unaddressed, these issues represent serious gaps that frequently lead to unplanned care and poor health outcomes.

Unlock the Value ofCommunity-Based Palliative Careto Close Clinical and Non-Clinical Care Gaps

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While many physicians and payers recognize the impact of these non-clinical care gaps, they lack a first-hand window into the member’s home to understand the breadth of these chal-lenges that face some of their seriously ill patients and families. Furthermore, physicians are being asked to engage and manage an even greater number of patients who are seriously ill and often require increased engagement and support. Add to this the pressures on physicians to take on more financial risk, increase care coordination through the medical home, handle time-consuming administrative tasks – and more. Clearly, these challenges require better support for physicians to provide high quality, patient-centered care for individuals with serious illness who are remaining at home.

This is where community-based palliative care (CBPC), a field that seeks to integrate palliative and serious illness care with established local community re-sources (such as specially trained nurses and social workers) is making a substantial difference in providing care for seriously ill members living at home. The optimal CBPC solutions effectively identify clinical and non-clinical issues, evaluate SDoH, improve care and quality of life and enhance the member and caregiver experience.

It’s a level of care that also represents great value for payers as they strive to gain increased visibility into the member’s home to better support the individual and caregiver. And while there is consensus that specialized CBPC provides a multitude of benefits for members, payers often lack a consistent, structured process for scaling this type of solution across their member populations and geographies—until now.

In this white paper, we examine key advantages of CBPC and the opportunity for payers to partner with an experienced provider that offers a specialized CBPC solution. It becomes evident that not all CBPC programs are the same.

“This is where community-based palliative care... is making a substantial difference in providing care for seriously ill members living at home.”

Source: https://www.capc.org/the-case-for-palliative-care/

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The Value of Process-Driven, Systemized CBPCEveryone in the healthcare continuum — members, caregivers, pro-viders and payers — benefit from a structured CBPC approach that is focused on identifying and addressing priority needs and aligning health care decisions with their goals and values.

One such innovative program, Turn-Key Health’s Palliative Illness Management™ (PIM™), is a highly specialized form of case manage-ment (CM) that starts with the basic tenets of CBPC and wraps them in structure and process to identify and close clinical and non-clinical care gaps.

A peer-reviewed study published in the April 2019 issue of the Journal of Palliative Medicine highlights the positive outcomes of the PIM program. Turn-Key’s systemized, structured and evidence-based care management program guides the palliative care clinician team—primarily nurses and social workers practicing at the top of their licenses. The study highlights how this approach results in more compassionate, affordable and sustainable high-quality care, reduced utilization and medical costs.

Understanding Clinical vs. Non-Clinical Issues of CareCoordination Clinical issues, such as direct diagnosis, treatment or testing, and reporting and documenting care back to the Patient Centered Medical Home (PCMH), can be formidable when it comes to members who are seriously ill, living at home and struggling with multiple issues on a daily basis.

PCMH standards focus on improved access to care coordination of medical services for patients and their caregivers. There are, however, some groups of patients with more complicated health care needs, such as those with serious illness who require more intensive medical services coordinated across multiple providers, as well as a wide range of social supports to maintain health and functioning. Because of the range and intensity of services needed, these patients tend to be the costliest. However, patients and payers benefit substantially from effec-tive care coordination across the full range of medical, mental health and social services.

What it requires is the deliberate organization of member care activities between two or more participants, including the member. All participants who are involved in a member’s care can play a role in facilitating the appropriate delivery of health care services and be better prepared to serve those who suffer complications. Because care is often fragmented, it is important to carefully organize personnel and other resources needed to carry out all required member care activities, which is often managed by the exchange of information among participants responsi-ble for different aspects of care.

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Beyond this, members are also dealing with non-clinical issues, such as the tasks of daily living, food insecurities or transportation arrangements to fill prescriptions or keep physician appoint-ments. These can represent serious gaps that negatively impact health and need ongoing atten-tion and resolution.

Enhancing Patient/Physician Engagement and Extending the Medical HomeCare fragmentation often makes it challenging to organize personnel, resources and relevant information for seriously ill patients. Therefore, it’s essential that patients be engaged with their physician and the medical home to achieve optimized care coordination and gain help for issues that impact everyday living, including those related to SDoH.

This is precisely where nurses and clinical social workers in CBPC provide a natural extension of the physician who is leading the medical home. They effectively increase the reach and frequency of patient engagement and interaction with physicians, applying a more structured approach to the medical home, streamlining reporting and communicating with providers. This results in synchro-nized care whereby physicians retain their established patient relationships while gaining much needed support for tackling other non-clinical issues.

Dedicated care teams provide in-home palliative assessments and interventions designed to extend physician visibility into the member’s home, identifying and filling both clinical and non-clinical gaps in care. This includes medication reconciliation, symptom management, caregiver support and care coordination back to the treating physician. It is an approach that incorporates sensitive conversations with members and caregivers around goals of care and advance care planning. These highly skilled clinicians can also provide telephonic and telehealth support.

Members with serious or advanced illness frequently face multiple challenges to care coordination, such as:

What follow-up appointments do I need to schedule?

How do I get equipment that may be needed for my care?

Who is going to help me manage my care at home, so I don’t return to the hospital?

How do I see my doctor or obtain my prescriptions if I can’t drive?

What if my symptoms get worse?

Can I get food delivered – or who will do the cooking?

I feel so alone, is there someone who can help me?

Achieving this level of coordination for both clinical and non-clinical issues is a key focus of specialized CBPC programs.

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It’s an extra layer of support for patients and families, with field-based clinicians that extend the reach and frequency of physician engagement. The palliative care team clinicians become the “eyes and ears” of the physician in the patient’s home.

This recipe for care coordination allows physicians to better focus on what they do best: provide high quality medical care. What’s more, it helps payers and providers to achieve the Triple Aim of improving the patient experience of care - including quality and satisfaction - improving the health of populations and reducing the per capita cost of health care. With this approach, all participants are better able to leverage community resources and remain informed about any challenges or care interventions that occur between regular patient visits.

Accounting for Social Determinants of Health SDoH has become highly relevant to achieving optimal member care coordination because it is designed to identify members who are plagued by social and economic conditions that indicate the greatest need for health improvement.

In the process, CMS is redefining how plans and healthcare providers address end-of-life care. The expectation is that physicians will play an increased role in the medical management of members with a serious illness who remain in the home setting.

This is where CBPC comes in: the clinician team zeroes in on SDoH factors that can lead to health plans being in a better position to improve care coordination that leads to lower ED utilization and pre-ventable readmissions. Members benefit from improved outcomes and, together with their caregivers, report increased satisfaction with care. In the case of the 84-year old, non-compliant woman with diabetes, a non-clinical issue in the home became a major impediment to controlling her insulin levels.

Furthermore, a CBPC model that addresses SDoH positively impacts quality improvement, member satisfaction and over-medicalization costs. It relieves suffering and improves quality of life for people of any age and at any stage, whether their illness is curable, chronic or life-threatening.

Turn-Key Health’s Palliative Illness Management (PIM)The primary goals of PIM are to: promote effective patient, caregiver and medical team engage-ment; align care and support patients’ and caregivers’ goals, preferences, values and health status; and improve patients’ quality of life and the use of resources throughout their illness and at the end of life.

PIM takes an innovative approach to CBPC that is grounded in:

1) sophisticated predictive analytics for patient identification

2) local palliative care teams to increase the reach and frequency of member engagement

3) standardized platform with embedded risk-based care paths and palliative assessments to guide, track and measure patient and caregiver interactions

“...a CBPC model that addresses SDoH positively impacts quality improvement, member satisfaction and over-medicalization costs ”

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Source: https://turn-keyhealth.com/home-based-palliative-care-programs-follow-needs-growth-medicare-advantage-plans/

Predictive Analytics

This member-centric, process-driven approach goes beyond the traditional referral model used by payers, using predictive analytics applied to payer claims data to identify members earlier in the disease trajectory. That data is further stratified to identify members who are predicted to experience an over-medicalized or inappropriate death.

Turn-Key Health uses a predictive model in combination with real time referrals from health plan case managers or others to identify members for the program. Our predictive model does not simply identify members at risk of death in the near-term or solely identify potential high-cost members. Instead, utilizing claims data and leveraging a powerful form of Artificial Intelligence (AI) and Natural Machine Learning (NML), our model identifies members that would benefit from palliative care and do so on a timelier basis.

Palliative Care Teams

Following member identification, PIM offers specialized care teams comprised largely of nurses and social workers who use structured assessments for home-based palliative care. PIM’s specialized approach serves not only as an extension of the physician, but just as importantly, the payer’s CM team. PIM helps the CM team to be more efficient and effective, sharing with them a member’s completed palliative assessments and care plans following calls or home visits. PIM also provides a robust suite of reports that provide important information about the population served, clinical outcomes, enrollment and disenrollment metrics and other highly relevant materials. This further extends the support of the existing CM team.

Social Determinants of Health

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Standardized Platform

The identified members are populated in Turn-Key’s PIM platform, which instructs and guides its affiliated community-based palliative care partners in member engagement and provides real-time reporting that includes engagement, clinical, activity and utilization metrics. The PIM palliative care program is designed to identify and address the physical, psychosocial and spiritual needs of patient/members/care givers and is guided by specially developed palliative assessments.

Additionally, throughout the assessment process, the PIM clinicians continually assess, through mo-tivational interviewing and key assessment questions, the impact of significant factors influencing end-of-life decision-making. These factors, termed the Palliative Activation Scale™ (PAS™), provide an evidence-based and systematic approach to foster continued improvements in the delivery of high-quality palliative care services to members/patients and caregivers. PAS helps clinicians to identify patients’ and caregivers’ priority needs, guides the timely selection of appropriate evidence-based interventions and assesses the effectiveness of an intervention over time.

PAS evaluates three key domains:

• Care Alignment - Those factors create harmony, understanding and acceptance of the care path desired by the member. They include family support systems, goals and expectations, provider engagement (including communication about prognosis), decisional balance, which incorporates the way the member uses knowledge to make choices that may positively (or negatively) impact the quality of remaining life, and their personal belief system.

• Social Determinants of Health (SDOH) - Those elements that are circumstantial but are directly correlated to the way a member approaches and an advanced or serious illness. The members’ age, religion and spirituality, socio-economic status, access to care, ethnicity and race can all positively (or negatively) influence their approach to care. Additionally, some SDOH factors or combination of factors may be so significant as to overwhelm any other influences. Taking the member’s SDoH into consideration during the initial and ongoing engagement will help inform a more productive interaction, resulting in a better outcome for the member

• Illness Trajectory - The degree to which the member’s health status has deteriorated as it relates to ADLs or functional status, as well as current symptom burden, significantly influences decision-making. The treatment plan and related underlying diagnosis and comorbidities are also indicators of illness trajectory. Drivers of acute care utilization (hospitalizations and ED visits) are frequently the result of all three domains.

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ConclusionPIM lies at the confluence of care coordination, member/physician engagement, the medical home and SDoH —and puts the member at the center of a highly structured care process. This more compassionate, affordable and sustainable level of care supports advance care planning, avoids unplanned care, reduces over-medicalization and helps case managers establish a more robust relationship with members.

The physician/member/payer relationship is the core of care and PIM is designed to serve as the specialized coordinating hub for all three. The PIM clinicians help to scale constrained medical resources by increasing the reach and frequency of care to provide the needed insights into how the member and caregiver are managing at home. When issues arise, interdisciplinary care teams engage and intervene quickly, which reduces the likelihood of unplanned hospitalizations or ED visits, and provide the member with greater satisfaction in how their care is managed.

When PIM’s care team went into Claire’s home, they discovered that her refrigerator didn’t work, making it impossible for her to preserve her medication and effectively manage her insulin levels. The PIM team got to the root cause of the problem, which was a non-working appliance that was causing non-adherence to her medication. They executed a quick and efficient resolution that not only resulted in a better health outcome, but also reduced the cost of care. In this case, it required care coordination with the patient’s caregiver and religious leaders, as appropriate, to get her a working refrigerator.

Process Means Progress: When a process-driven, systemized approach to CBPC is used to close both clinical and non-clinical gaps in care, payers make real progress in bringing a specialized pal-liative care solution to members across the enterprise. The positive impact upon quality improve-ment, member satisfaction and over-medicalization can be measured, with progress benchmarks achieved day in and day out.

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Yosick, Lori et al; Effects of a Population Health Community-Based Palliative Care Program on Cost and Utilization; Journal of Palliative MedicineVol. 22, No. 9; Sept. 3, 2019; https://www.liebertpub.com/doi/full/10.1089/jpm.2018.0489; accessed October 21, 2019.

Rich E, Lipson D, Libersky J, Parchman M; Coordinating Care for Adults With Complex Care Needs in the Patient-Centered Medical Home: Challenges and Solutions; AHRQ Publication No. 12-0010-EF; Agency for Healthcare Research and Quality; January 2012; https://pcmh.ahrq.gov/page/coordinating-care-adults-complex-care-needs-patient-centered-medical-home-challenges-and; accessed October 21, 2019.

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Turn-Key Health, an Enclara Healthcare company, serves health plans, provider organizations and their members who are experiencing a serious or advanced illness. Its Palliative Illness Management™ (PIM™) model introduces a new, innovative option to improve care quality,

address costs and reduce burdens associated with life-limiting illnesses.

www.turn-keyhealth.com

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