Circle of Life Honoree - LifeCourse

Topic: Expanding the IDT

Patients living with serious illness struggle to navigate the currently fragmented healthcare system. Services such as home care, palliative care, and hospice offer critical, person-centered support, but are underutilized and often only offered during certain episodes of late life care. The need for innovative, upstream palliative care models is critical.

Allina Health has developed a cost-effective innovative model—LifeCourse—to support patients facing advanced serious illness and their friends and families. Patients receive monthly in-home visits from a community health worker called a care guide, who builds a long-term supportive relationship with patients while providing whole person care. The LifeCourse approach is based on best practice palliative care guidelines; as well as feedback from patients, caregivers, and providers. The care guides use question sets and assessment tools to help patients articulate what matters most and empower them to seek the care that aligns with their preferences. Patients and families are also connected to needed medical and community based resources. Care guides are integrated into an existing care team; positioning them to facilitate communication about patient preferences in-person and via the electronic health record.

Results from a quasi-experimental cohort research study that included 900 participants have shown that patients participating in LifeCourse have better care experiences and have less decline in quality of life. Hospice length of stay was increased and patients had 16 percent fewer emergency department visits, 27 percent fewer inpatient days, and 57 percent fewer ICU stays. This lowered utilization contributed to healthcare cost savings and resulted in an 8:1 return on investment.

Based on these results, LifeCourse is successfully implemented within a large Midwestern healthcare system, in primary and specialty care, as well as in enterprise-wide care management services. LifeCourse is also currently implemented in an independent FQHC. To successfully implement LifeCourse within existing care teams at each site, a LifeCourse implementation team met with clinic leaders and key clinic staff over several weeks to gain buy-in from and educate key stakeholders about LifeCourse and to hire the care guides. The LifeCourse team worked to adapt program materials to meet the needs of their population, and review care guide protocols to make sure the clinic team understood the care guide work and how they add value. In addition to following a detailed implementation strategy, an evaluation plan was created to measure the effectiveness and provide feedback on the process and outcomes. The LifeCourse team also provided ongoing training and technical assistance with regard to providing person-centered care and integrating LifeCourse into each site.

Author

  • Jessica Taghon, BA
  • Research Associate
  • Allina Health
  • 2925 Chicago Avenue, MR 10039
  • Minneapolis, MN 55407
  • (612) 262-1595

Co-authors

  • Anne Betzner, PhD
  • Paige Bingham, MBA
  • Vivian Anugwom, MS

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