On a cold Monday morning Thomas Cornwell, M.D., climbs into the back of an SUV. A primary care physician, he is en route to the home of an elderly dementia patient in the Chicago suburbs who recently enrolled in hospice.
Cornwell and a medical assistant spend close to 40 minutes in the patient’s home, checking the patient’s status, medications, and vitals; completing medical record documentation and leaving orders for the patient’s hospice provider and instructions for the caregiver. He spends some time speaking with the patient’s paid caregiver to help prepare him for the patient’s eventual death.
Cornwell, founder of Northwestern Medicine HomeCare Physicians and CEO of the Home Centered Care Institute, coordinates care for this patient with the interdisciplinary team from Suncrest Hospice. Though no formal contractual relationship binds the two providers, their work exemplifies the type of care coordination that forthcoming payment models are designed to encourage, such as the Primary Care First initiatives set to begin in 2021.
“There’s a fair amount of communication that goes on between the two organizations. All hospices have medical directors and one of the questions that they ask the primary care provider is whether we want to continue to be the main doctor, and we always do because we know our patients,” Cornwell told Hospice News. “A lot of doctors aren’t necessarily comfortable with the comfort medications and symptom control, and so sometimes they want the hospice medical director — who is really comfortable with end-of-life care — to take over. In our case, we definitely welcome their input, but we remain in charge of the patients we know so well.”
Improved care coordination is an underlying goal of the Primary Care First payment structures unveiled in April by the U.S. Centers for Medicare & Medicaid Services (CMS). Partnerships with primary care providers could be the key for hospice and palliative care providers seeking to capitalize on the emerging payment models.
Hospices and palliative care organizations are eligible to participate in the payment models provided they meet the program’s criteria. The program will be implemented in phases beginning in January 2021, initially in 26 regions around the country, though CMS eventually expects to expand the program.
Eligible providers have two payment options under the program: A general payment option and a Seriously Ill Population payment option designed to serve patients with complex, chronic needs, for which providers would receive increased payments. Eligible providers, including hospice and palliative care practitioners, can choose to participate in one of those options or both simultaneously.
“Care coordination was a clear theme in introducing the Primary Care First and the Seriously Ill Population options. It is it is meant to foster partnerships and collaboration,” Allison Silvers, vice president of payment and policy at the Center to Advance Palliative Care, said. “Some of the things that are emphasized in Primary Care First is providing intensive services and then being clear on what the next steps are when the patient stabilizes, and that’s all about partnerships. CMS considers a successful transition to mean no emergency department visits or hospitalizations in the three months after the transition, and you are not going to be able to do that without good coordination and collaboration.”
Among the goals of Primary Care First is to create a seamless continuum of care, according to CMS. The payment options also are designed to test whether delivery of advanced primary care can reduce health care costs, asking eligible primary care practices to assume financial risk in exchange for reduced administrative burdens and performance-based payments.
Though Northwestern Medicine HomeCare Physicians and Suncrest Hospice do not have a financial relationship that results in shared payments or cost savings as would exist in a Primary Care First-oriented partnership, they demonstrate how a hospices can work together with primary care providers to coordinate patient-centered care.
Whether on the primary care or hospice side, the patient’s wishes and goals greatly inform the trajectory of care.
“When choosing a hospice provider the patient’s choice is paramount. We make sure we are transparent with patients and families and that the patient’s choices are our most important consideration,” James Sperka, director of clinical services for Suncrest, told Hospice News. “What we see is that the health care model is shifting care delivery towards the patient’s home. There is nothing like a hospice team to allow patients and family to do that. Patients feel more safe and comfortable in their homes, and some are unable to come to a doctor’s office or other location without great difficulty.”
Home-based primary care and hospice complement each other well to meet the full spectrum of a terminally ill patient’s needs, according to Cornwell. Northwestern Medicine HomeCare Physicians is a component of a large Chicago area-based health system that employs more than 1,000 doctors. The program’s two physicians make 12% of the entire system’s hospice referrals.
“We tend to get patients close to the end of life. Doctors tend to refer patients to [the home-based primary care program] when they know the patient can no longer get into their offices. So we work with hospice a lot,” Cornwell said. “We have a mutual relationship in which they provide nurses, aides and social workers that we don’t provide, and we provide the medical knowledge they need for orders, medication and equipment.”