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

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

Last Updated: February 3, 2019

2016 essay on how palliative care and population health efforts can work best together. Casarett and Teno, 2016.

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Serious Illness Strategies

Last Updated: February 3, 2019

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.

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The Guide to Integrating Palliative Care into Population Management

Last Updated: February 28, 2019

Guidance on the six strategies for implementing high-value care for the population of patients with serious illness, and suggested first steps.

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Improving the Care of Serious Illness Though Innovative Payer-Provider Partnerships- A Palliative Care Toolkit and Resource Guide

Last Updated: January 29, 2019

Designing a payer-based program that ensures specialized support for members with serious illness. Center to Advance Palliative Care, 2016.

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Serious Illness Strategies for Health Plans and ACOs

Last Updated: August 11, 2019

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

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Communicating with Treating Clinicians about the Implications of Frailty

Last Updated: February 3, 2019

Identifying patients with frailty who are at high risk for health care utilization and adverse outcomes.

Learn from early adopters and jump-start population management efforts using recommended methods for patient identification, risk stratification, assessment, case management, and quality measurement.

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Case Study: ProHealth

Last Updated: February 3, 2019

ProHealth, a multi-specialty physician practice ACO, uses home palliative care for high-need patients.

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Case Study: Sharp Healthcare

Last Updated: February 3, 2019

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

Last Updated: June 14, 2019

Training complex case managers in communication skills and deprescribing. CAPC and the Accountable Care Learning Collaborative.

Improving Value in a Large Health System by Transforming the Care of People Living with Serious Illness: A Case Study from Trinity Health System

Last Updated: August 21, 2019

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

Last Updated: June 14, 2019

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

Last Updated: June 14, 2019

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

Last Updated: June 14, 2019

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

Last Updated: February 3, 2019

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

Last Updated: February 3, 2019

Partnership Health plan, a regional plan in California, uses a small set of outcome measures in its contracts with palliative care programs.

Recommended Standards for Hospitals and SNFs

Last Updated: July 30, 2019

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

Last Updated: February 3, 2019

Overview of the payment arrangements that currently exist for palliative care services.

Patient Identification and Assessment

Last Updated: March 4, 2019

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

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

Last Updated: March 4, 2019

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.

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Serious Illness Strategies for Health Plans and ACOs

Last Updated: August 11, 2019

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

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