The Delaware Valley Accountable Care Organization (ACO) has leveraged a comprehensive, community-based palliative care program developed by its partner Main Line Health to reduce costs of care by $9,000 per eligible patient.
Among Delaware Valley’s palliative care recipients, hospital admissions were 50% lower and emergency department visits fell by 35%, generating about $9,000 in savings per patient during the last 90 days of life, according to Beth Souder, the ACO’s vice president of clinical operations.
“All our data was pointing to the fact that we had a huge opportunity at end of life and our patients with serious illnesses. So, with Main Line building this program, our job as an ACO is to stratify populations based on data,” Souder told Hospice News. “The serious illness population was a population of focus for us for longitudinal care management, and we needed a toolbox for our providers and for our care coordinators. Main Line’s program is that kind of toolbox.”
The seeds of the program were planted by a keynote speech by Dr. Diane Meier at a Delaware Valley ACO conference. Meier is the founder, director emerita and strategic medical advisor to the Center to Advance Palliative Care (CAPC).
Meier’s talk inspired Main Line Health to begin assessing its palliative care programs for opportunities to expand, according to Terre Mirsch, the Pennsylvania-based health system’s executive director of home care and hospice.
“She shared with us things about the differences that palliative care can make for people who are experiencing serious illness,” Mirsch told Hospice News. “But what it really did is grab the attention of other senior leaders in the health system, and raise awareness of a gap that we had in our palliative care delivery system.”
Main Line Health already had a robust palliative care program, including for its hospital inpatients and community-based services through its home health program. But gaps existed in care delivery, created in part by the strictures of home health eligibility requirements.
Patients must be homebound with needs that require skilled services, for example.
“Not all patients with serious illness meet that criteria. So, therefore, we had a gap. You either need to be in the hospital, which we were trying to avoid, or you need to be sick enough to be homebound and have those skilled nursing needs,” Mirsch said. “That’s what this program was really designed to do, to fill that gap. They need support in between all of those exacerbations or crises.”
While Main Line recognized that palliative care was “the right thing to do for patients,” they also had to build the business case, particularly when reimbursement opportunities are limited, according to Mirsch. The key to this was the anticipated reductions in the total cost of care.
Their care model is interdisciplinary, including nurse practitioners, social workers and chaplains. The organization was also able to share staff among its programs, such as palliative care and home health or hospice, as well as for back office support and scheduling.
Main Line’s palliative care program also had another benefit — it boosted the organization’s hospice enrollment rates.
“Many hospice programs offer palliative care programs because they envision that that will be a feeder to their hospice program. That was not our primary goal; this is our way of helping them further upstream,” Mirsch said. “But I was realistic enough to know that that might be a secondary outcome. If more patients enrolled in hospice for a longer period of time, that would be fabulous news.”
Meanwhile, the ACO began looking at decedent data among its Medicare-shared savings population and compared those who had received home-based palliative care to those that had not.
While they found that some costs went up — hospice and home health spending, as well as durable medical equipment — these were more than offset by reduced hospitalizations and skilled nursing facility admissions, as well as lower Part B expenses.
After seeing Main Line’s results, Delaware Valley set about scaling palliative care to its other ACO members, starting by vetting their existing programs. Several of those organizations have developed or enhanced their programs, though not all used the model pioneered by Main Line.
Delaware Valley also developed an enhanced advance care planning toolkit that substantially increased utilization.
According to the ACO’s current calculations, the palliative care program could produce more than $3 million in annual savings if only 25% of its seriously ill population were enrolled, regardless of whether they were nearing the end of life.
With these results in mind, Delaware Valley has plans to expand the model.
“This work is the beginning, and we’re going to take this further because now we also have a preliminary return on investment in our serious illness population in general,” Souder said. “And we are seeing per-member per-month savings.”