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

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.

Serious Illness Strategies: Driving Value in High-Need Populations

A summary of implementation best practices for health plans and ACOs driving value in the care of high-need, seriously ill populations.

Serious Illness Strategies for Health Plans and ACOs

Webinar presentation on a population health approach to care for patients with serious illness.

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.

Best Practices in Serious Illness Care for MA Plans and ACOs

A summary of do's and don'ts for serious illness care across four key strategies. CAPC and Better Care Playbook

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.

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.

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.

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.

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.

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.

Case Study: Mercy Health: Virtual Palliative Care Add-on

Mercy Health, a 135,000 lives ACO, added in palliative care consultations virtually to the top 5% of its virtual complex care patients.

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.

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.

Case Study: Advancing Coordinated Palliative Care during a Pandemic: Hudson Headwaters Health Network

A document detailing how Hudson Headwaters, a rural ACO covering 125,000 lives, deployed competent communicators to network facilities to significantly reduce avoidable hospital transfers.

Case Study: Payer-Led ACP at Dean Health Plan

A document detailing how Dean Health Plan, a large HMO in the midwest, successfully identified and engaged members in goals of care and advance care planning conversations.

Home-Based Palliative Care Program Summaries

An excerpt from CAPC's Home-based Guide, at-a-glance review of program models.

Improving 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.

Aetna's Compassionate Care Program

This article describes a care manager-led intervention and includes an analysis of its financial impact.

Additional resources to use when integrating palliative care into population management at your health system.

Recommended 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.

Patient Identification and Assessment

Toolkit for finding the right patients at the right time to address gaps in care.

Care Managers: Addressing the Unique Needs of Patients with Serious Illness

This toolkit provides online courses and resources for care managers to meet the needs of patients with serious illness.

Serious Illness Strategies Medicare Advantage Learning Community

CAPC has convened Medicare Advantage and ACO organizations for an in-depth learning experience on the four Serious Illness Strategies.

Serious Illness Questions for EMR

An adaptation of Ariadne Conversation Guide to build into a health system EMR. Ariadne Labs and Integra ACO.

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