By Greer Myers, President, Turn-Key Health
A growing number of healthcare payers are seizing the opportunity to optimize their population health management (PHM) programs for seriously ill patients. A new platform makes it possible to use predictive analytics to identify members who are most at risk for utilization of non-beneficial treatment (NBT) and extends the value of PHM by introducing community-based palliative care teams to engage these members and caregivers in informed decision-making that avoids NBT.
This identification process is critical to transitioning from disease or event-specific care management activation to an approach addressing the person, the patient, and the process. Focusing on NBT as it relates to truly patient-centered care enables payers to accomplish the triple aim in healthcare.
While predictive data analytics alone are not the total solution, they are key to identifying the appropriate at-risk patients who will benefit from specialized interventions. This patient identification is valuable in launching innovative care models which provide support and education to patients about their treatment options. Payers can then leverage resources with the intent to help patients make better quality of life choices that better support their personal wishes and goals of care, resulting in the avoidance of NBT.
This innovative model utilizes specialized palliative interventions, support tools, and assessments to further optimize PHM initiatives. Structured palliative care, providing relief from the symptoms and stress associated with advanced illnesses, are now available as part of the Palliative Illness Management™ (PIM) program. By introducing PIM, payers reduce the cost of care, members are more satisfied with the care they receive, and individuals experience improved quality of life.
Importance Of Palliative Interventions
These members are broadly defined as those who are suffering with an advanced illness, usually during the final 12 to 18 months of life. It often involves one or more conditions that become serious enough that general health and functioning decline and medical interventions begin to lose their positive benefit and in many cases become detrimental to quality of remaining life.
The PIM algorithm, as an example, identifies patients through regressive analysis who are likely to die within 6 to 12 months, as well as those at risk for NBT. Examples of NBT future events identified by the model include:
- chemotherapy for cancer patients within 14 days of death
- unplanned hospitalization within 30 days of death
- one emergency department (ED) visit within 30 days of death
- ICU admission within 30 days of death
- life-sustaining treatment within 30 days of death
Once these individuals are identified through the PIM algorithm, appropriate palliative illness management strategies can be put into place. The goal is to intervene earlier in the disease trajectory, enhance care coordination, and provide improved quality care at lower cost.
Unfortunately, most general strategies to PHM often fail to provide this breadth of service for NBT avoidance. With no meaningful, consistent, systematic way of addressing this need, these members are frequently subjected to NBT.
Benefits Of PIM
The PIM care model engages with underserved populations earlier in their disease trajectory, utilizing specially trained nurses, social workers and other clinicians.
PIM builds dedicated community-based palliative care teams, answering the call for a value-based payment model that allows for reimbursement of nurses and social workers with experience, expertise, and training in offering high-touch clinical services. This differs markedly from parallel programs that rely upon on fee-for-service billing to Medicare Part B by physicians or nurse practitioners. A scalable and financially feasible program that extends the value of PHM, PIM obviates the need for time and resource-intensive recruitment and hiring of medical doctors (MDs) and nurse practitioners (NPs) for primary intervention.
These teams assist with care coordination and improve patient and caregiver understanding of treatment options during the last months of life. They facilitate a structured approach to patient engagement, establishing risk-based palliative care paths and protocols that are embedded in the PIM platform, which supports one-to-one relationships with members, families and healthcare providers:
- telephonic and home visit assessments
- establishes care management infrastructure
- focuses on care coordination across all settings
- emphasizes ongoing support at home
- ensures goals of care discussion
- facilitates advance care planning
- engages physicians and other care providers
- provides integrated, dedicated interdisciplinary team-based care
This motivational interviewing/ assessment process facilitates sensitive discussions led by experienced palliative care clinicians who encourage people to consider, discuss, and document their future wishes for care. Fortunately, the number, affordability, and availability of community-based palliative care clinicians is increasing, offering payers “on-the-ground” teams that can lead these conversations. Companies are now acting as conveners between palliative care specialists, payers, and members in collaborative relationships to improve quality of life.
PIM provides an extra layer of support, is appropriate at any age and at any stage in a serious illness, and can be provided along with curative treatment. It is a model that enables payers to specifically address the needs of these members with a refocused and expanded scope of palliative interventions to address social, behavioral, and psychological issues. These concerns take on even more relevance when a member chooses to remain in the home setting.
Finally, it creates opportunities to achieve appropriate outcomes by supporting the medical home, improving care coordination, and avoiding expensive hospitalizations, re-admissions, and ICU days.
Conducted by nurses and social workers, PIM home visit assessments include:
- identification of primary and secondary diagnoses
- medical and hospitalization/ed history
- functional status and activities of daily living
- symptom assessment and management
- medication review; adherence assessment
- adequacy of home, family, safety & financial supports
- patient’s understanding of illness
- goals of care/advance care planning
- services in place or needed
- patient risk evaluation
- palliative plan of care
- patient’s understanding of illness
The Value Of Earlier Introduction Of Palliative Interventions
When members with advanced illnesses are identified by predictive analytics, payers have an opportunity to introduce palliative care services sooner, rather than relying on referrals that frequently come very late in the illness trajectory, if at all. Integrating PIM earlier in the care process, and regardless of the place of care or treatment plan, not only helps to ensure suffering doesn’t go unnoticed and untreated, but also results in better health outcomes, higher satisfaction with care, and reductions in healthcare costs.
Earlier introduction of palliative interventions is a significant benefit to members who need and value this level of assistance. It allows members to receive in-home support that rationalizes decision-making before embarking on a path of NBT, which is rarely consistent with patient wishes or underlying goals of care. It’s also an effective approach to relieving the high-stress which often accompanies day-to-day living with life-limiting conditions, helping individuals and their family to cope with new or worsening symptoms and the financial consequences of high co-pays for expensive interventions.
While this type of program has been available on a limited basis as a part of an end-of-life modality, it is gaining recognition as a key component of overall PHM strategies. With the emergence of specialty PHM companies that partner with payers to deploy community-based palliative care models, health plans, Accountable Care Organizations and at-risk provider groups are better equipped to support this fragile population.
About The Author
Greer joined Enclara Health in 2014 and maintains dual roles as President of Turn-Key Health and Executive Vice President of Corporate Development. Bringing strengths in post-acute operations, mergers and acquisitions, pharmacy benefits management, strategy and business development, he also has strong vertical experience in payer, provider, and healthcare IT verticals. Previously, he was the founder and CEO of the early stage end-of-life population health management company, Care Trajectory, LLC.