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Home-Based Palliative Care: High Touch, Value-Based Approach Leads to Better Outcomes for Seriously Ill Patients
By Say Salomon, MD, and Terri Maxwell, PhD, APRN

The COVID-19 pandemic highlights the disproportionate impact of highly infectious disease upon those people who are seriously ill, placing burdens upon primary and specialty care practices to provide care to older adults living at home. As a result, many practices choose to partner with a provider of home-based palliative care (HBPC) as a way to extend the reach of their practices and strengthen patient engagement.

A growing number of primary care clinics recognize the important role of HBPC to meet the complex needs of the low-income and ethnically diverse senior populations who are seriously ill. Prior to the pandemic, demand for in-home care was expected to exceed supply by more than 3 million in the next decade and this need is expected to remain high. These clinics require assistance to extend the reach of HBPC programs to meet the needs of the nation’s most vulnerable and chronically ill older adults who will benefit from a holistic and supportive palliative care approach.

The idea is to focus on delivering personalized care around proven standards to address complex health challenges. This requires a high-touch primary care approach based on value, not volume, with primary care doctors seeing patients as often as needed to personalize, prioritize, and optimize medical care. HBPC teams serve as the “eyes and ears” in the patient’s home to detect and manage multiple and major chronic health conditions with an emphasis on preventing unnecessary emergency department (ED) visits or in-patient hospital admissions.

Now more than ever, the needs of people with serious illness extend beyond the medical model of health to include social supports, symptom relief, care coordination, communication, and decision support. However, most patients have limited access to services outside the medical model to help support their quality of life.

Collaboration and partnerships with specialized HBPC partners can help clinics improve the patient/family experience and outcomes by providing an additional layer of support to their patients with serious illness. The optimal HBPC partner can deliver a highly structured, evidence-based clinical program to increase the capacity for providing palliative services in patients’ homes. The program should also deliver advanced disease management to improve patients’ quality of life and end-of-life experience in collaboration with primary care providers as the leaders of the care team.

How an HBPC Solution Works
HBPC clinicians, including specially trained nurses and social workers, develop relationships with seriously ill patients and their caregivers through telehealth and home-based support, which includes symptom management, medication reconciliation, and psychosocial/spiritual support, documentation of advance care plans, care coordination, and mobilizing community support services.

An effective HBPC clinician team provides nonmedical services to identify gaps in care and address social determinants of health, such as insecurities related to food, transportation, and social isolation. These teams develop a trusting relationship that enables them to understand the patient’s physical, mental, spiritual, and emotional needs. They provide ongoing psychosocial support and assist patients’ and their caregivers’ understanding of the illness and goals of care. They also arrange for community-based resources, such as arranging transportation and meal delivery, helping with utility and grocery bills, filling prescriptions, arranging for in-home equipment, and providing health coaching and care training. The goal is to help patients remain safe at home and reduce caregiver burden.

Typically, HBPC clinicians meet weekly to review patient cases and participate in monthly interdisciplinary meetings with the community clinic team to discuss complex patient and family cases. The nurses and social workers provide ongoing support until the patient stabilizes and no longer requires services, moves out of the service area or into a long term care facility, or enrolls in hospice.

HBPC initiatives also enable primary care clinics to meet enrollment benchmarks and document goals of care and advance care plans. HBPC clinicians manage symptoms, reduce caregiver stress, and decrease unplanned care, such as ED visits and hospitalizations.

Benefits and Benchmarks
For caregivers, an HBPC solution relieves burden/stress, supports aging at home, and aligns patient and family goals. In fact, patients receiving these services report high satisfaction with symptoms despite having poor health.

The added layer of HBPC support contributes to a primary clinic’s advanced disease management programs to achieve high levels of patient and caregiver satisfaction, ensure that care provided is consistent with patient and family goals, coordinate care across settings, and increase hospice election.

HBPC programs have been shown to significantly exceed clinical key performance indicators with respect to the following:

• goals of care discussed and documented;
• advance directive documented and health care proxy documented;
• medication reconciliation; and
• satisfaction with symptoms.

Case Study
Mrs. S. is a 74-year-old woman diagnosed with ALS. When initially enrolled in an HBPC program, she used a wheelchair full time and needed help with most activities of daily living. She received food via a flexible tube (percutaneous endoscopic gastrostomy, or PEG). Her only child lived out of state and she had no friends or family locally. She communicated by typing on her phone or writing because she could no longer speak. Mrs. S. wanted to maintain her independence and remain at home. She completed an out-of-hospital DNR, but she was very reluctant to discuss hospice. The HBPC social worker arranged for her to receive 11 hours of in-home long term care per day, seven days a week. The social worker also functioned as a mediator between Mrs. S, her son, and aides. The RN worked diligently to monitor Mrs. S for disease progression, coordinate care, and report findings to her primary care physician and interdisciplinary team. As the patient’s condition worsened, the social worker and RN collaborated to transition her to hospice. She later died peacefully under hospice care.

COVID-19 Prompts Pivot From Facility to Home Care
During the COVID-19 pandemic, HBPC teams have played a critical role, seeing patients with urgent needs in the home when necessary—following strict guidelines for screening and use of personal protective equipment—and reaching out by phone or video to help patients access food and prescription refills and organize delivery of other supplies to minimize patient exposure.

HBPC teams also continue to evaluate symptoms and provide education and support to help patients better manage their chronic conditions. Individually and collectively, HBPC teams provide a personal connection to help combat social isolation and assess for signs of depression, anxiety, or other mental and emotional status changes. These teams also conduct COVID-19–specific advance care planning discussions using specially developed communication and decision support tools.

Patient Story
Betty is a 74-year-old woman with lung cancer who lives alone and has no children or family to help her. Her severe mobility issues prevent her from leaving the second floor of her home. While the daughter of her physical therapy aide comes twice a week to leave her cooked vegetables, the lack of proper nutrition is beginning to affect Betty’s health. This has led to numerous preventable and unnecessary ED visits.

Betty’s primary care provider and HBPC team of experts assessed the situation and put a food delivery service into place so that organic, locally prepared meals are delivered daily to her home. Doing so improved Betty’s nutritional status and reduced her social isolation. This simple solution prevented costly clinical issues and resulted in a more compassionate, affordable, and sustainable level of care for Betty and other patients like her.

HBPC programs are becoming an essential component for building a better model for care at home to address clinical and nonclinical issues and resolve the challenges associated with social determinants of health. During this challenging time, fee-for-service practices have been at a significant disadvantage compared with those offering value-based care.

First, fee-for-service practices did not immediately pivot to the safety of telemedicine prior to community spread of COVID-19 due to uncertainty about telemedicine payment. In contrast, value-based care practices earn predictable per-member per-month fees for each patient served from Medicare Advantage plans to cover all care needs for each patient.

Second, fee-for-service practices are largely unable to see care outcomes once the patient shifts to receiving care at home. Home-based medical care was on the rise for this high-need population, even before the pandemic: according to one study, about 5% of Medicare patients surveyed had received home-based care from 2011 to 2017, and 75% of beneficiaries in that group were homebound. HBPC programs mitigate the effects of isolation on an individual’s physical and mental health; ensure coordinated, proactive care for serious illness; and improve quality of life for the patient and caregiver.

HBPC provided by care team members specially trained to help identify and resolve social, financial, environmental, and emotional challenges holds extraordinary value for patients and caregivers and significant promise for practices and payers seeking innovative ways to provide a higher level of supportive care in the home.

— Say Salomon, MD, is national medical director of acute and postacute care and associate director of palliative care at ChenMed, a privately owned medical, management, and technology company that delivers the high-touch and personalized primary care Medicare-eligible seniors need to enjoy better health.

— Terri Maxwell, PhD, APRN, is general manager and chief clinical officer at Turn-Key Health, a CareCentrix company serving health plans, provider organizations, and their members who are experiencing a serious or advanced illness.