July/August 2020

Closing Care Gaps
By Greer Myers
Today’s Geriatric Medicine
Vol. 13 No. 4 P. 10

Community-based palliative care improves quality and care coordination.

Our health care system is facing unprecedented challenges in managing the clinical and nonclinical issues facing older adults burdened by a serious illness. As patients age and the likelihood of recovery from an advanced illness declines, their health care problems become more pronounced. The extraordinary growth of the geriatric population, changes in Medicare Advantage to include benefits addressing social determinants of health (SDOH), and the shift to home-based care are some of the factors that influence clinical and nonclinical management of this population.

The increase in the number of older adults who are living longer and facing serious or advanced illness is increasing. The number of Americans aged 65 and older is projected to nearly double from 52 million in 2018 to 95 million by 2060, and the 65-and-older age group’s share of the total population will rise from 16% to 23%. Approximately 85% of older adults have at least one chronic health condition, and 60% have at least two chronic conditions, according to the Centers for Disease Control and Prevention.

As the center of care shifts outside the hospital and into patients’ homes, older adults are struggling with clinical and nonclinical issues in their home environments and now require a higher level of support. Physicians are tasked to continue to provide high-quality patient-centered care for individuals with serious illness who are remaining at home.

Relevant to caring for this population, the Centers for Medicare & Medicaid Services now recognizes home-based palliative care in supplemental benefits related to SDOH. These include issues related to disease exacerbation, unmanaged symptoms, access to care, health literacy, food scarcity, home/neighborhood safety, social supports, and family/caregiver issues. When patients are grappling with complex clinical and nonclinical issues related to serious or advanced illness, they require more intensive medical services from their medical and social support teams to maintain health and functioning. What is needed is a process to identify and engage with these older adults in order to resolve the myriad issues associated with SDOH.

Value of Care Coordination
Physicians shoulder a large portion of the burdens of care for members who are seriously ill, living at home, and struggling with multiple challenges on a daily basis. Clinical issues such as direct diagnosis, treatment or testing, and reporting and documenting care back to the patient-centered medical home (PCMH) can be formidable, with PCMH standards focused on improved access to care coordination of medical services for patients and their caregivers.

There are, however, some groups of patients with more complicated health care needs, such as those with serious illness or advanced illness who require more intensive medical services coordinated across multiple providers, as well as a wide range of social supports to maintain health and functioning. Because of the range and intensity of services needed, these patients tend to be the costliest. However, patients and payers benefit substantially from effective care coordination across the full range of medical, mental health, and social services.

Research shows that 30% of people 65 years old and older need care from a geriatrician, and that each geriatrician can care for as many as 700 patients. This translates to a larger demand for geriatricians—and the need for geriatricians is only expected to grow. There are roughly 7,300 certified geriatricians currently practicing in the United States, but the American Geriatrics Society expects 30,000 geriatricians will be needed by 2030. Clearly, geriatricians must engage and manage an even greater number of patients.

Partnering With CBPC Resources
As physicians dedicate themselves to achieving the highest quality of care for older adults, they increasingly welcome partners that provide models of care to overcome the challenges cited previously. As the market demands that they take on more financial risk, increase care coordination through the medical home, and handle time-consuming administrative tasks, partnerships with community-based palliative care (CBPC) organizations become highly attractive for physicians as well as patients.

CBPC is a field that seeks to integrate palliative and serious illness care with established local community resources. CBPC in the patient’s home not only improves care quality and care coordination but also increases patient engagement and enhances their satisfaction with the health care experience. In addition, it presents an opportunity to address clinical and nonclinical issues, including SDOH.

Validation for the Need to Address SDOH
Research and technology have revealed the depth of the impact social factors have on health and health care costs. A McKinsey & Company report found that nonmedical factors—including the conditions in which people are born, grow, live, work, and age—can have an enormous impact on health. From economic stability and education to access to healthy foods and reliable transportation, these social factors can influence an individual’s ability to effectively manage their health and get the right care when they need it.

Access to healthful foods, for example, is central to good health and healing, but 35% of respondents experienced food insecurity. These same people were more than twice as likely to have multiple emergency department visits over a 12-month period. In fact, social determinants matter more to health outcomes than do medical services: SDOH drive more than 80% of health outcomes. Sixty-eight percent of patients face at least one barrier related to social determinants. Of these, 57% have a moderate to high risk for financial insecurity, isolation, housing insecurity, lack of transportation, food insecurity, and/or low health literacy.

Specialized CBPC helps to converge SDOH awareness, research, and health care innovation in a way that’s helping improve the health care landscape for every stakeholder.

Understanding the Impact of SDOH
Too often, overlooked nonclinical issues and SDOH can affect care quality. This ranges from something as unexpected as a broken refrigerator for storing medications such as insulin to other issues, such as food insecurity, low health literacy, or the lack of transportation, which often makes it a challenge to get to the pharmacy to fill a prescription or attend physician appointments. Left unaddressed, these issues represent serious gaps that frequently lead to unplanned care and poor health outcomes.

While many physicians acknowledge the impact of these nonclinical care gaps, they lack a firsthand window into the patient’s home to understand the breadth of these challenges that face some of their seriously ill patients and families.

Consider this example of how seemingly small challenges in the patient’s home can escalate into a catastrophic health-related event, resulting in suboptimal outcomes and significant health care expenditures. Doris, a 75-year-old woman with COPD, lives alone and has no children. A lifelong smoker, she’s on continuous oxygen, and, because of her isolation and inability to get out, she’s suffering from depression. She’s also subsisting mostly on crackers and candy bars. During the winter, her substandard living conditions exacerbate both her COPD symptoms and depression, which has led to frequent visits to the emergency department. With the introduction of a CBPC solution as described previously, both clinical and nonclinical issues were resolved.

CBPC: Improving Quality and Care Coordination
CBPC is making a substantial difference in providing quality care and closing gaps in care for seriously ill patients living at home. A population health–centric model of CBPC takes this approach to an even more sophisticated and dynamic level. It uses predictive analytics to identify patients earlier in the disease trajectory and predicts who is likely to experience an overmedicalized or inappropriate death. This approach integrates structure and process into programs, services, and in-home assessments and deploys dedicated clinician teams—including specially trained nurses and social workers—to engage with patients and caregivers in the home setting.

CBPC nurses and professionals are specially trained to spend time in the patients’ homes and identify unaddressed clinical issues and physical symptoms and determine basic social needs that might prevent patients from addressing important goals of care and advance care planning.

This is an opportunity to treat the whole patient, connect with them upstream, help them cope better with their illness, and mitigate its impact on their quality of life. It’s about addressing the simple needs of life first and providing access to resources, because a patient who is going hungry, for example, will be less inclined to focus on obtaining and taking medications.

In the case of Doris, the CBPC team made an initial home visit and observed her lighting a cigarette with her oxygen on via nasal cannula. When the nurse stopped her, Doris said she wasn’t aware that it was a fire hazard. The nurse provided immediate education on oxygen safety. The nurse also researched the patient in the EPIC system and found contact information for her brother. Her brother not only began bringing fresh food and Ensure for Doris on a regular basis but also agreed to continue to visit Doris as often as possible—all of which improved her safety, diet, depression, health status, and quality of life.

How CBPC Works
Typically, patients who require palliative care are identified through claims data that reflect such things as clinical information, hospital visits, diagnoses codes, and doctor visits. This information is of high value but reveals very little about the patients’ lives in the home environment. Nevertheless, their clinical needs are tied to their social needs, such as housing, food insecurity, financial or social fragility, or lack of a caregiver.

With a specialized CBPC program, patients are stratified, and the clinically more complex cases receive a visit from a specially trained CBPC nurse case and/or social worker who consults with the primary nurse to determine the type and intensity they need.

For instance, a patient who lives alone and has no caregiver or transportation will require more attention from the social worker, while a patient with an infected wound may only need attention from a nurse. In this way, CBPC relieves suffering and improves quality of life for people of any age and at any stage—whether their illness is curable, chronic, or life threatening.

A peer-reviewed study published in the April 2019 issue of the Journal of Palliative Medicine demonstrated the positive outcomes of a systemized, structured, and evidence-based care management program that resulted in more compassionate, affordable, and sustainable high-quality care, reduced utilization, and lower medical costs.

By providing needed insights and visibility into how the patient and caregiver are managing at home, specialized CBPC teams can quickly resolve problematic issues—such as arranging to replace a broken refrigerator by coordinating with the patient’s caregiver and religious leaders, finding a neighbor who can drive a patient to a community day care to relieve loneliness, or arranging to have prescriptions delivered directly to the home for patients who don’t have transportation. Such quick and efficient resolutions not only result in a better health outcome but also significantly reduce costs related to caring for these patients.

Structured, Process-Driven CBPC in Action
The CBPC approach serves not only as an extension of the geriatrician but also as the payer’s case management team. For example, Turn-Key Health’s Palliative Illness Management utilizes dedicated community teams of nurses and social workers who make structured palliative assessments and interventions to evaluate and manage gaps in care, support care coordination, and address SDOH.

The idea is to start with the basic tenets of CBPC and wrap them in structure and process. Specialized care teams comprising largely nurses and social workers use structured assessments for home-based palliative care. This process-driven approach goes beyond the traditional referral model, using predictive analytics to identify patients earlier in the disease trajectory.

The primary goals are to promote effective patient, caregiver, and medical team engagement; align care and support patients’ and caregivers’ goals, preferences, values, and health status; and improve patients’ quality of life and the use of resources throughout their illnesses and at the end of life.

This innovative approach to CBPC is grounded in sophisticated predictive analytics for patient identification, local palliative care teams to increase the reach and frequency of patient engagement, standardized platforms with embedded risk-based care paths, and palliative assessments to guide, track, and measure patient and caregiver interactions.

The identified patients are populated into a platform that instructs and guides its affiliated CBPC partners in patient engagement and provides real-time reporting that includes engagement, clinical, activity, and utilization metrics. This more specialized approach to CBPC is designed to identify and address the physical, psychosocial, and spiritual needs of patients and caregivers and is guided by specially developed palliative assessments.

Additionally, throughout the assessment process, the program clinicians continually assess, through motivational interviewing and key assessment questions, the impact of significant factors influencing end-of-life decision-making. These factors, termed the Palliative Activation Scale (PAS), provide an evidence-based and systematic approach to foster continued improvements in the delivery of high-quality palliative care services to patients and caregivers. PAS helps clinicians identify patients’ and caregivers’ priority needs, guides the timely selection of appropriate evidence-based interventions, and assesses the effectiveness of an intervention over time.

PAS evaluates the following three key domains:
1. Care Alignment: Factors that create harmony, understanding, and acceptance of the care path desired by the patient. They include family support systems; goals and expectations; provider engagement (including communication about prognosis); decisional balance, which incorporates the way the patient uses knowledge to make choices that may positively (or negatively) influence the quality of remaining life; and their personal belief system.

2. SDOH: Elements that are circumstantial but directly correlated to the way a patient approaches an advanced or serious illness. The patients’ ages, religion and spirituality, socioeconomic status, access to care, and ethnicity and race can all positively or negatively influence their approach to care. Additionally, some SDOH factors, or combination of factors, may be so significant as to overwhelm any other influences. Taking the patients’ SDOH into consideration during the initial and ongoing engagement will help inform a more productive interaction, resulting in a better outcome for the patients.

3. Illness Trajectory: The degree to which the patient’s health status has deteriorated as it relates to activities of daily living or functional status, as well as current symptom burden, significantly influences decision-making. The treatment plan and related underlying diagnosis and comorbidities are also indicators of illness trajectory. Drivers of acute care utilization (hospitalizations and emergency department visits) are frequently the result of all three domains.

Relieving the Burdens on Geriatricians
Achieving a higher level of care coordination for both clinical and nonclinical issues is a key focus of specialized CBPC programs. The aim is to relieve the burden for geriatricians by tackling multiple challenges that patients with serious or advanced illness frequently face and addressing patient concerns, such as the following:

• What follow-up appointments do I need to schedule?
• How do I get equipment that may be needed for my care?
• Who is going to help me manage my care at home, so I don’t return to the hospital?
• How do I see my doctor or obtain my prescriptions if I can’t drive?
• What if my symptoms get worse?
• Can I get food delivered, or who will do the cooking?
• I feel so alone. Is there someone who can help me?

CBPC Helps Physicians Deliver Better Care
As physicians focus on an array of concerns that go well beyond basic patient care, they are also navigating an evolving Medicare landscape and value-based payment models that emphasize quality vs quantity.

Moreover, in an environment that often reflects a fragmented approach to care, physicians find it increasingly important to carefully organize personnel and other resources needed to carry out all required patient care activities, which is often managed by the exchange of information among participants responsible for different aspects of care.

The CBPC approach for care coordination allows physicians to better focus on what they do best: provide high quality medical care. What’s more, it helps payers and providers to achieve the triple aim of improving the patient experience of care—including quality and satisfaction—improving the health of populations and reducing the per capita cost of health care. With this approach, all participants are better able to leverage community resources and remain informed about any challenges or care interventions that occur between regular patient visits.

Around the country, physicians, hospitals, and health plans are rising to the challenge and improving the health of people and populations they serve by helping to address some of life’s most basic needs—housing, clothing, food, isolation, and transportation—with some surprising results. A more holistic approach to patient care, exemplified by a CBPC solution, results in improved cost and quality metrics and much needed relief from the mounting pressures now confronting our nation’s physicians.

— Greer Myers is president of Turn-Key Health. With more than 20 years of health care experience, Myers joined Turn-Key Health as president in 2015. Bringing strengths in postacute operations, mergers and acquisitions, pharmacy benefits management, strategy, and business development, he also has strong vertical experience in payer, provider, and health care IT verticals.