Piloting the Care Management and Palliative Care Program

Topic: Measuring Impact and Value


The goal of the Care Management and Palliative Care Program (CMAP) is to improve quality of life, and provide dignity and respect for homebound patients.  Interventions include:  intensive care management, incorporation of palliative medicine principles into care, utilization of patient centered care strategies for decreasing hospital utilization (therefore increasing time at home).  Equally important is a focus on the patient oriented outcomes of increased symptom assessment, goals of care discussions, and completion of advance directives.

 We identified a population within our home visit practice which is high risk for readmission and death.  Eligibility: ≥ 60 years old, a hospitalization or ED visit, approval from the patient’s primary team of providers, scoring ≥ 5 on the risk scoring tool applied after hospital/ED visit.  The scoring tool is currently being validated and is based on internal data of homebound patients with high utilization and includes: utilization of hospital or ED (numeric), number of chronic conditions (CHF, COPD, ESRD, CVA, bedbound status, stage 3 or 4 pressure ulcers, AIDS, and advanced cancer), dual-eligible status , length of stay, hospital readmissions (numeric).

Analysis six month pre and post intervention (n=51)  has shown a significant decrease in hospital or ED visits from an average of 59 ED visits pre-CMAP program to 32 ED visits post-CMAP and from 142 inpatient visits pre-CMAP program to 51 visits post-CMAP program.  Length of stay has been reduced from 16 days to 3.3 days on average pre-post intervention. Number of 30 day readmissions in the cohort decrease from 21 to 13.  Patients are staying out of the hospital for an average of 84 days post intervention.  One-hundred percent of patients have had discussions about completing advanced directives and 89% of patients have them scanned into the chart. One-hundred percent of patients have a documented symptom assessment.

The CMAP program demonstrates that using population health and palliative care principles improves outcomes for patients, paving the way for future outpatient palliative care initiatives in a home-based setting. The program demonstrates decrease in utilization of hospital/ED visits, 30-day readmission, and hospital length of stay. Results also demonstrate a more consistent approach to applying palliative interventions such as goals of care discussions and symptom assessment, which were completed in 100% of patients.

Next steps include validating the risk scoring/trigger tool, comparing the CMAP group to a historical cohort, dissemination of findings, and applying for future funding opportunities to continue this work.

Ultimately the CMAP team has been able to tailor care to the individual’s needs with the goal of improving quality of life and respecting patients’ health care choices, while improving health care system utilization.


  • Linsey D. O'Donnell, DO
  • Faculty, Department of Family and Community Medicine
  • Christiana Care Health System
  • 4755 Ogletown Stanton Rd.
  • Newark, DE 19718
  • (302) 320-5700


  • Ina Li
  • Kristen Isaac
  • Linsey D. O'Donnell

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