Integrating Palliative Care into Population Management
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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.
Serious Illness Strategies: Driving Value in High-Need Populations
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A summary of implementation best practices for health plans and ACOs driving value in the care of high-need, seriously ill populations.
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 Home-based Palliative Care in an ACO
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ProHealth, a multi-specialty physician practice ACO, uses home palliative care for high-need patients.
Sharp Healthcare, an integrated network of hospitals and clinicians, incorporates a home palliative care intervention to meet the needs of complex patients.
Case Study: Integrating Palliative Care Into Primary Care Workflows at Mayo Clinic
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Use of palliative care-trained social workers to improve primary care for people living with serious illness. CAPC and the Accountable Care Learning Collaborative.
OSF, a large, faith-based health system, implements a systemwide Advance Care Planning Initiative. CAPC and the Accountable Care Learning Collaborative.
Anthem, a health plan operating across 14 states, includes palliative care structure and process measures in its quality incentive program for network hospitals.
Case Study: Advancing Coordinated Palliative Care during a Pandemic: Hudson Headwaters Health Network
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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.
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.
Case Study: Trinity Health Improving Value in a Large Health System
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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: Sustained Value for Our Members with Advanced Illness
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An analysis of a health plan-led program of communication interventions and connection to palliative care and hospice, resulting in a significant decline in acute care utilization (Baquet-Simpson et al.).
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 27 resources:
The Case for Communication and Symptom Management Training
Clinical Training Recommendations for All Clinicians Caring for Patients with Serious Illness
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