Population Management and Palliative Care
Last Reviewed: March 4, 2019
Organizations working to improve the quality and efficiency of care must focus on the needs of the population living with serious illnesses. This palliative care toolkit is a collection of practical tools to identify, risk-stratify, and meet those complex needs.
What’s in the Toolkit
Comprehensive Guidance
Best practices for systematically improving value in the care of people living with one or more serious illness, gleaned from health systems, health plans, and accountable care organizations (ACOs) from across the country. The approach includes proactive patient identification, risk stratification, effective patient engagement and care planning, training and equipping the provider network to meet patient and family needs, and implementing appropriate quality measures and incentives.
Why Population Health and Palliative Care Need Each Other
2016 essay on how palliative care and population health efforts can work best together. Casarett and Teno, 2016.
viewSerious Illness Strategies
The case for health plans and accountable care organizations to advance access to quality palliative care, and practical guidance for implementation. Center to Advance Palliative Care, 2017.
downloadThe Guide to Integrating Palliative Care into Population Management
Guidance on the six strategies for implementing high-value care for the population of patients with serious illness, and suggested first steps.
downloadImproving the Care of Serious Illness Though Innovative Payer-Provider Partnerships- A Palliative Care Toolkit and Resource Guide
Designing a payer-based program that ensures specialized support for members with serious illness. Center to Advance Palliative Care, 2016.
downloadSerious Illness Strategies for Health Plans and ACOs
Webinar presentation on a population health approach to care for patients with serious illness.
watch
Communicating with Treating Clinicians about the Implications of Frailty
Identifying patients with frailty who are at high risk for health care utilization and adverse outcomes.
members loginCase Studies and Resources
Learn from early adopters and jump-start population management efforts using recommended methods for patient identification, risk stratification, assessment, case management, and quality measurement.
Case Study: ProHealth
ProHealth, a multi-specialty physician practice ACO, uses home palliative care for high-need patients.
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Case Study: Sharp Healthcare
Sharp Healthcare, an integrated network of hospitals and clinicians, incorporates a home palliative care intervention to meet the needs of complex patients.
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Case Study: Case Manager Training in Action at Integra ACO
Training complex case managers in communication skills and deprescribing. CAPC and the Accountable Care Learning Collaborative.
members loginImproving Value in a Large Health System by Transforming the Care of People Living with Serious Illness: A Case Study from Trinity Health System
Trinity Health's journey to expand access to specialty palliative care across settings, and train all clinicians to identify and address sources of suffering for patients with serious illness.
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Case Study: Integrating Palliative Care Into Primary Care Workflows at Mayo Clinic
Use of palliative care-trained social workers to improve primary care for people living with serious illness. CAPC and the Accountable Care Learning Collaborative.
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Case Study: Moffitt Cancer Center’s Approach to Standardizing Palliative Care and Oncology Integration
Use of screening to risk-stratify patients for palliative care based on need. CAPC and the Accountable Care Learning Collaborative.
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Case Study: OSF Healthcare
OSF, a large, faith-based health system, implements a systemwide Advance Care Planning Initiative. CAPC and the Accountable Care Learning Collaborative.
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Mini-Case Study: Anthem
Anthem, a health plan operating across 14 states, includes palliative care structure and process measures in its quality incentive program for network hospitals.
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Mini-Case Study: Partnership Health Plan
Partnership Health plan, a regional plan in California, uses a small set of outcome measures in its contracts with palliative care programs.
members loginRecommended Standards for Hospitals and SNFs
Structures and processes that all hospitals and skilled nursing facilities need to assure access to high-quality care for people with serious illness.
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Payment Arrangements Options
Overview of the payment arrangements that currently exist for palliative care services.
members loginPatient Identification and Assessment
Toolkit for finding the right patients at the right time to address gaps in care.
viewCase Managers: Addressing the Unique Needs of Patients with Serious Illness
This toolkit, Case Management for People with Serious Illness, provides online courses and resources for case managers to meet the needs of patients with serious illness.
viewSerious Illness Strategies for Health Plans and ACOs
Webinar presentation on a population health approach to care for patients with serious illness.
watch
Related Toolkits See all 30 toolkits
Tools to design and implement a training initiative for care teams from all specialties, to improve quality of life for patients and families living with serious illness.
Includes 21 resources:
- The Case for Communication and Symptom Management Training
- CAPC Curriculum
- Training by Specialty or Discipline
- Implementing a Training Program
