Fragmented health care has significant ties to adverse outcomes in patients with chronic or serious illnesses.
Palliative care providers’ ability to navigate the health care system, coordinate the delivery of care, interact regularly with patients and facilitate communication between providers can reduce this fragmentation. This type of coordination can improve outcomes, decrease costs and offer patients a better quality of life.
Navigating system challenging for patients
Critiques of current care coordination often focus on the disjointed experiences patients have when dealing with multiple providers, specialists and other services. When patients are very ill, obtaining medicines, transportation, durable medical equipment (DME) or home health may not occur because caregivers do not have resources or are overwhelmed.
“We found that most of the patients participating in these kinds of programs are relatively late in their disease process, and so they are not in a situation where they have the ability to coordinate all of these issues on their own,” Dr. Christopher Comfort, CEO of Calvary Hospital, told Palliative Care News.
Calvary is the only acute-care hospital in the United States that focuses almost exclusively on hospice and palliative care.
“Care coordination is so important for patients, especially if their goal is to maintain in their home setting and avoid hospitalization,” said Aimee Anderson, manager of care management, for Alivia Supportive Care. “We’re used to navigating the medical system and [that familiarity] takes a little pressure off of the family.”
Create a well-structured program
Seriously ill patients are very difficult to manage, and palliative programs have the resources and time to provide the needed services.
“Palliative care programs [that] include care coordination provide a very structured, efficient and competent way to guide patients with late-stage disease,” Comfort said.
The home-based models offered by Calvary and Alivia have a care team that coordinates visits, regularly checks on patients and facilitates conversations between practitioners. These models also coordinate community resources based on medical needs, social determinants of health or other needs.
Develop good care coordination practices
“Good coordination of care has three aspects,” Comfort said. “One is consistent interaction with the patient and family so that there is truly monitoring of the patient. The second is [coordination of] decisions that are being made by practitioners. And lastly, when it’s done properly, it’s a wonderful opportunity to monitor the care plan.”
Establishing good rapport with patients and families is also important so they feel comfortable calling for support and resources, according to Anderson.
Comfort and Anderson recommended other best practices:
- Instituting interdisciplinary meetings including patients and families every 2-3 weeks to foster shared knowledge and home care plans for greater effectiveness.
- Standardizing questions for bi-weekly check-ins with the patient. This enables practitioners to quickly identify problems. It also develops a consistent language between patients, families and practitioners.
- Implementing mandatory communication between practitioners. Every visit with a patient reveals new information about how a patient’s disease is progressing, said Anderson. Comfort agreed and said Calvary’s requirement of a verbal or written update about the patient’s status benefits both patients and providers.
Identify, track benefits and cost savings
This model of care coordination can prevent emergency department (ED) visits and hospitalizations, assure compliance with treatment regimens and relieve the patient and their family of the burden of coordinating physicians, medical care and community-based resources.
“Cost savings to the system in general is really based upon the ability of care coordination to prevent high-cost expenditures for that patient during a period of time the patient is observed,” said Comfort.
However, the actual cost savings of care coordination by palliative care is under debate. A commentary on a JAMA study acknowledges a majority of positive interventions with care coordination, but significant variance in the population studied.
To truly quantify the cost savings, palliative care providers must analyze the data. However, accessing claims data has historically been difficult for palliative care, Comfort said. Additionally, many palliative care programs have not been around long enough to collect and compare historical data.
With the Center for Medicare & Medicaid Innovation’s emphasis on value-based payment models, analysis of these data to make the case for palliative care’s ability to coordinate care across settings is growing in importance. Well-analyzed data will also strengthen referral partners’ confidence and interest in working with palliative care.
