Plans in Prgress: CHCF Payer-Prvider Partnerships fr Palliative Care December 2015 While health care prvider rganizatins, payers, and the health plicy cmmunity increasingly recgnize the deficiencies in care fr peple with serius illness and the rbust evidence f the benefits f palliative care, grwth f cmmunity-based services thse ffered utside the acute care hspital and prir t enrllment in hspice has been stunted by the lack f sufficient, defined funding streams. T address this challenge, the Califrnia HealthCare Fundatin (CHCF) engaged 10 pairs (r triads) f payer and prvider rganizatins in a six-mnth planning prcess t identify sustainable appraches fr delivering high-quality, cmmunity-based palliative care t patients with serius illness. CHCF made planning grants t these entities t supprt this effrt: 1. Califrnia Pacific Medical Center with Sutter and Brwn & Tland (San Francisc) 2. CareCHOICES Hspice and Palliative Services with Health Net (Orange Cunty, Lng Beach, and Suth Ls Angeles) 3. Cmmunity Reginal Medical Center with Humana (Fresn) 4. LightBridge Hspice & Palliative Care with Health Net (San Dieg) 5. Optum Palliative and Hspice Care with UnitedHealthcare (Orange Cunty) 6. Partnership Health Plan with varius palliative care prviders (Nrthern Califrnia) 7. Rady Children's Hspital with Health Net (San Dieg) 8. SCAN Health Plan with MemrialCare Medical Grup and Mnarch (Orange Cunty) 9. UCLA with Anthem (Ls Angeles) 10. UCSF with Hspice by the Bay and Blue Shield (San Francisc) By the end f the planning perid, each team had develped an implementatin plan that detailed the target patient ppulatin, mdel f care, funding apprach, and metrics. This dcument describes the variety f appraches develped by the payer-prvider teams and may prvide fd fr thught fr ther rganizatins cnsidering similar partnerships. Patient Ppulatin What patients will be targeted t receive specialty palliative care, and hw will they be identified? Critical t the success f any specialty palliative care interventin is defining which patients the palliative care team will serve. If teams cast t large a net, using criteria that yield t many patients r patients that are unlikely t benefit frm palliative care, they will verwhelm their services and dilute their impact n clinical and fiscal utcmes. If targeting criteria are t restrictive, teams may miss pprtunities t reach patients whse physical r psychscial distress they culd effectively address, as well as pprtunities t prevent avidable hspitalizatins r emergency rm visits.
There is n ne "right" way t define which patients are apprpriate fr palliative care teams use different appraches based n variatins in prgram gals, clinical resurces, and available data. Amng the Payer/Prvider Partnership planning grant teams, criteria fr targeting patients fr their palliative care services included cmbinatins f these variables: Estimated life expectancy: Ranges frm "ne year r less" t "18 mnths r less" t "12 t 24 mnths." Sme teams plan t use explicit prgnstic criteria t estimate life expectancy, while thers expect t rely n (subjective) prvider assessments, r a cmbinatin f the tw. Diseases: Sme services plan t accept patients with any chrnic r serius illness, prvided there is evidence f specific cmrbidities r debility / functinal decline. Other services will target specific cnditins r cmbinatins f cnditins, including metastatic cancer (may specify certain types f cancer), chrnic bstructive pulmnary disease, cngestive heart failure, cirrhsis, dementia, and frailty syndrme. Age: Used by sme teams t narrw the patient ppulatin, such as under age 18 fr pediatric patients, r age 90 r abve. Utilizatin: Sme teams plan t use histry f emergency department (ED) and hspital use, such as tw r mre visits/admissins ver six mnths, r same-diagnsis admissin within 30 days. Gegraphy: Mst specify the cities r cunties that a given prvider will serve. Teams develped a range f strategies fr implementing the abve criteria, including: Database search: Sme teams plan t use payer claims data t identify patients wh are high utilizers f high-acuity services such as the hspital r ED, and sme will use predictive mdeling tls t assess risk f mrtality r readmissin. Chart review: Often used as a supplement t a palliative care team member using a database search as a starting pint in patient screening. This step is ften needed if nn-cded values, such as functinal status, are used in determining eligibility. Referral: Referrals frm primary care and specialty prviders, health plan nurses and case managers, hspital discharge planners, as well as self-referrals frm patients and families. Mdel f Care What services will be prvided t patients, by whm, and where? The term "palliative care" can mean different things t different peple. As payers and prviders cllabrate t imprve access t palliative care services, they must reach agreement n the mdel f care, clarifying issues such as: Services t be prvided: May include assessment and management f physical and psychlgical/psychiatric symptms, emtinal and spiritual issues, scial and functinal issues; assessment and dcumentatin f patients' values and wishes, including gals f care Plans in Prgress: CHCF Payer-Prvider Partnerships fr Palliative Care 2
discussins and advance care planning dcumentatin; case management; and crdinatin f transitins acrss settings and prviders Intensity and duratin: Hw frequently and fr hw lng patients are seen by different members f the interdisciplinary team, defining different tiers f care depending n patients' needs Staffing: Cmpsitin f interdisciplinary team, rle f different team members in prviding services Lcatin: Where services will be prvided, such as a stand-alne clinic; a clinic-based service embedded r clcated with anther medical specialty; at a patient's residence (may include private hmes, assisted living facilities, nursing facilities); by telephne r videcnference; r acrss settings Outreach: Hw the service will engage prviders and/r patients and families t infrm them f the available services Amng the Payer/Prvider Partnership planning grant teams, mdels f care vary acrss all f the elements abve. Sme trends include: Hme-based services: A majrity f the teams plan t prvide exclusively r predminantly hme-based palliative care services, sme in crdinatin with inpatient palliative care services, ften augmented with phne-based r videcnference interactins between prviders and patients. The ne team planning t prvide exclusively clinic-based services (plus phne supprt) will be embedded in an nclgy clinic. Interdisciplinary care: Palliative care services will be prvided by interdisciplinary teams, including sme cmbinatin f physician, nurse practitiner, registered nurse, scial wrker, and less frequently, chaplain, pharmacist, r patient care attendant. Sme will invlve ther types f care prviders within their rganizatins, utside f the cre palliative care team (such as psychlgists, grief cunselrs, and massage therapists). Sme plan specific intervals and/r tuchpints fr different members f the care team t interact with patients, such as having the nurse r scial wrker d an initial screening, the physician r nurse practitiner d the initial care visit, and the nurse care crdinatr prviding nging care. Tiers f care: Defining different tiers f care based n patient acuity and needs, with variatin in the intensity and duratin f services, which disciplines are invlved, and care setting. These may range frm weekly visits by a physician r nurse practitiner fr the patients with greatest need, t semimnthly r mnthly phne calls frm a scial wrker r nurse case manager fr mre stable patients. Outreach: Includes a variety f methds t educate prviders abut services, including grup and nen-ne meetings, use f brchures r newsletters (fr prviders and patients/families), referral frms r triggered cnsults that identify apprpriate patients, and general educatin abut palliative care and advance care planning aimed at prviders as well as patients and families. Plans in Prgress: CHCF Payer-Prvider Partnerships fr Palliative Care 3
Funding Apprach Hw will payers cmpensate prviders fr palliative care services? Partnerships between payers and prviders t increase access t palliative care services must include payment mdels that enable bth parties t sustain the partnership ver time. Payment mdels will vary based n the type f palliative care services prvided, the staffing mdel, the anticipated impact n care quality and ttal health care csts fr the targeted patient ppulatin, and the degree f risk each party currently has r is willing t take n fr the target patient ppulatin. The planned funding appraches f the teams vary widely, illustrating the need fr flexibility in this new and dynamic field. Teams' planned initial appraches include: Enhanced fee-fr-service, where payments fr individual encunters are increased t reflect invlvement f team members such as nurses, chaplains, and scial wrkers, as well as greater length f individual encunters Per-member-per-mnth payments, which wuld cver all specialist palliative services ffered t a member r a subset f services (fr example, all cmmunity-based services) Tiered mnthly bundled service rate based n patient characteristics and needs Shared-savings r shared-risk arrangements Cmbined appraches, such as a per-member-per-mnth base payment fr ne specific set f services, fee-fr-service payments fr additinal sets f services, and shared savings based n key quality indicatrs Additinal "pay fr reprting" incentives that reward cllectin and reprting f detailed prcess and utcme data Additinal "pay fr perfrmance" incentives that reward psitive utcmes Teams will evaluate and ptentially adjust their funding appraches ver time based n pilt phase experiences. Metrics / Mnitring Impact Hw will partners assess the impact f their palliative care services? T understand the impact f their palliative care services n care quality, utilizatin f health services, and fiscal utcmes, payer/prvider partners must agree n a set f metrics they will cllabratively mnitr. This metrics strategy will vary based n the gals f the palliative care prgram frm bth the payer and prvider perspectives, data availability, and analytic resurces but shuld generally include a balanced prtfli f indicatrs that feature: Structure metrics: What is in place t serve patients and families; team cmpsitin, training, and availability (including, fr example, prgram staffing, services ffered, and lcatins, settings, and availability f services) Prcess metrics: Describe the wh, what, where, when, and why f the service; fr example: Plans in Prgress: CHCF Payer-Prvider Partnerships fr Palliative Care 4
Wh: Which patients were seen? What prprtin f the ptential ppulatin was seen? What: What did the palliative care team d? Pain management, advance care planning, spiritual supprt? Where: Where were services prvided? When: When were services prvided, relative t time f diagnsis, time f death, r time f referral? Why: What were the reasns that palliative care was asked t help? Were these apprpriate? Outcme metrics: Describe the impact f clinical cntacts: On patients: Fr example, what was the impact f palliative care n pain scres and ther symptm scres? On families and care teams: Fr example, hw satisfied were families with the services prvided? On institutins: Fr example, the impact f palliative care n hspital use. Are csts reduced? Are there fewer in-hspital deaths? The tp 10 metrics prpsed by the CHCF Payer/Prvider planning grant teams included: Prprtin f patients cmpleting Advance Care Plan / POLST frms Use f palliative care service (number f individuals referred, enrlled, refused; time n service; number f encunters, number f encunters by discipline, number f different lcatins f encunters [fr example, clinic, hme, phne]) Hspital (number f admissins, number f readmissins, apprved days) Emergency Department (number f visits) ICU (number f days) Hspice (referral rate, acceptance rate, length n service) Patient/family satisfactin scres Management f pain and ther symptms Site f death (percentage dying at hme, percentage dying in preferred lcatin) Referring prvider satisfactin / likelihd f using service again Plans in Prgress: CHCF Payer-Prvider Partnerships fr Palliative Care 5