Las Vegas-based Nathan Adelson Hospice has developed a unique, value-based contracting model with United Healthcare to provide financially sustainable palliative care to Medicaid-enrolled patients to improve their quality of life and reduce hospital readmissions. 

Nearly 87% of the patients enrolled in the program suffer from cancer, though patients with congestive heart failure or chronic obstructive pulmonary disease are also eligible to participate.

The model relies on the traditional palliative care interdisciplinary team model, with a high degree of coordination with United Healthcare’s community resources to address social determinants of health, which is a tremendous needs among that patient population, according to Nathan Adelson’s Chief Medical Officer Clevis Parker.

“United had a certain population that they struggled with in regards to rehospitalization and symptom management,” Parker said. “We negotiated a deal where we could provide integrated palliative care services for their Medicaid patients. When we went to the table with [United], I think we both had an idea of what we wanted, and we crafted an outline of the structure of the model that we wanted to deliver.”

The model involved intensive services during the first few weeks involving home visits and phone calls from nurse practitioners, nurses and social workers.

During the first week, the palliative care case manager from United HealthCare would make the referral to Nathan Adelson, whose intake staff would make an initial evaluation appointment. This is followed by an eligibility screening and a discussion of the program between the nurse are manager and the patient and family, followed by an initial assessment and development of a plan of care.

The palliative care team would take quick action to address any urgent medical or psychological needs, refer the patient to a pharmacy, as well as offer resources for housing, food, mental health issues, or additional social determinants of health, which were a significant contributing factor to hospital readmissions among these patients.

“We found that this particular population is challenged with a lot of social determinants of health, including things like access to a medication or pharmacy, and all the issues you often see with the Medicaid population who need resources that often are not available,” Parker said. “Because of that they rely heavily on the hospital system to address those needs.”

Prior to contracting with Nathan Adelson, the readmission rate among these patients was 100%, Parker said. The rate is currently at 80% and dropping.

In weeks two through seven of the program, a nurse follows up with the patient weekly, alternating between calls and home visits. During this time they care team works with the patient and family to establish goals of care, provide symptom management, coordinate services to meet basic medical and nonmedical needs, and begin discussions about the patient’s wishes and preferences for end-of-life care.

Advance care planning is a key component of the program. Within the first few months of the program 14 of 23 patients had a Physician’s Orders for Life-Sustaining Treatment (POLST) document.

In the third phase of the program, weeks three through 10, a nurse would follow up every two weeks, stabilize any new issues that may have emerged, revisit advance care planning discussions, and the interdisciplinary team continues to provide symptom management, as well as emotional and spiritual support.

Through the contract with United HealthCare, the model is financially sustainable, which is a challenge for most home- or community-based palliative care programs.

“We initially budgeted for 75 patients in the pilot program, and we only hit almost 40, so we fell short in terms of the number of admissions, but overall the program has had a positive impact on our bottom line,” Parker told Hospice News. “The dollar amount is enough for us to say that it is worth continuing to pursue more contracts that are similar. I think it’s also been helpful for our palliative care program that in general that hadn’t had a lot of funding except through philanthropy.”

Discussions are underway at Nathan Adelson about how to expand the program beyond the Medicaid population to include those covered by commercial insurance, as well as potentially partnering with hospitals, Accountable Care Organizations, physician group practices or other providers to help reduce their readmissions and support their patient needs.

One challenge that caused slow admissions in the first phases of the program was how to identify the patients in need of these services. United HealthCare had a program champion who was responsible for determining whether patients who were admitted to the hospital or who came into the emergency department were eligible for the program. Though projects are underway to identify patients more quickly and effectively, including implementation of systems that rely on algorithms, for the time being this remains the program’s biggest challenge.

A second obstacle was developing systems to coordinate care among the various stakeholders, including United Healthcare’s care managers and community resources.

“The C-suite has an idea of what they want, but you have to engage with the people on the ground doing the work,” Parker explained. “We took our idea and had separate conversations with [United’s] medical director and case managers and some of the different plays in the community. We needed their buy-in, and they gave us good support and feedback. We assured them that we were not going to take their place or leave them out of the process, we are adding to the services that they already provide.”