Programs that integrate both palliative care and home-based primary care are proving effective at improving patients’ quality of life and reducing health care costs.
Combining and coordinating those two forms of care can also allow a palliative care provider to access patients sooner as well as offer a more comprehensive suite of services, according to Dr. Paul Chiang, medical director for Northwestern Medicine HomeCare Physicians (HCP) and senior medical and practice advisor for the Home-Centered Care Institute.
Bringing together home-based primary care is a win-win for patient and health care providers, Chiang said at the HAP Foundation’s Serious Illness Symposium in Naperville, Illinois.
“There is an intersection between what we do, goals-of-care conversations, referrals to hospice, supporting a patient and a caregiver, symptom management,” Chiang said. “We do a lot of the similar things. How can we bring the circles together closer to help our patients?”
In addition to being a primary care physician, Chiang is board certified in hospice and palliative medicine and to date has made more than 37,000 house calls to more than 3,600 patients.
The average age among patients of Northwestern Medicine HomeCare Physicians is about 82, according to Chiang, most of whom have multiple advanced or chronic illnesses. The organization also cares for younger patients who have suffered catastrophic illnesses or injuries and have a high risk of hospital readmissions, such as those with cerebral palsy, traumatic injuries and combat veterans.
A 2017 analysis of Northwestern’s program showed significant cost reductions, reduced hospital readmissions and increases in hospice enrollment and length of stay, Chiang said at the symposium.
Offering these services in the home can also help take some pressure off of physician offices and hospitals themselves, by taking on their most complex patients.
“We also take care of a lot of complex patients to help with the primary care provider [(PCP)] office flow. There’s a lot of talk about access; the PCPs are overwhelmed. Their schedules are not accommodating,” Chiang said. “We can help take some of the complex time demanding patients away from a PCPs office, provide them with great care, improving access both ways. This will open up office opportunities for less intense medical individuals to see PCPs.”
A similar dynamic exists with hospitals seeking to free up capacity and prevent patients from returning within 30 to 60 days of discharge. Unlike home health, home-based primary care and palliative care patients are not required to be homebound in order to receive those services.
For home-based primary care, providers rely a great deal on technology, including portable devices for doing X-rays, EKGs, ultrasounds and a centrifuge to analyze blood draws, to name a few.
As with other home-based services, the major challenges for both palliative care and primary care in the home are the workforce shortage and reimbursement. Chiang’s program at Northwestern, for example, operates on a fee-for-service model that limits their options for interdisciplinary staff. The program is in the process of hiring its first social worker as a part-time employee.
Chiang said that he expects to have greater flexibility as the health care system migrates toward value-based payment models.
“We are extremely lean because of the fee for the service structure that I’ve worked under,” Chiang said. “Weare optimistic that there’s a payment reform that’s coming. There’ll be a different financial chassis that we can put the practice on that will reimburse me in a different way. That will allow me access to more money that I can use to hire a pharmacist or social worker or whoever I think will benefit my patients.”