New palliative care model may ease transition from acute care to hospice
Patient-focused case management is at the heart of the program
Palliative care experts are watching an experimental program being tested in Kentucky to learn whether it will address the problem of providing a broad range of care to people who are ineligible for hospice services but who still need social services, pain management, and spiritual care.
While the advent of inpatient palliative care centers facilitates provision of palliative care to people who have been admitted to hospitals, there still are people who do not require acute care, as well as those who are largely confined to their homes but are not technically homebound and thus are ineligible for home care. For many of these people, pain relief is elusive, and caregivers continue to struggle with the demands of caring for someone with a chronic illness.
Officials at Passport Health Plan, a small HMO in Louisville, KY, say they have found a solution to the financial barriers preventing access to palliative care and other services. Passport Health Plan is the operating name for University Health Care, Inc., a Medicaid managed care plan that serves the Medicaid and KCHIP populations in Region 3 of the Commonwealth of Kentucky.
Nurse case managers coordinate care
Passport was established in 1997 by a group of providers with a history of serving Medicaid patients. They include University of Louisville Hospital, Jewish Hospital, Norton Healthcare, and the Louisville/ Jefferson County Primary Care Association, which includes the Jefferson County Health Department and Louisville’s two federally qualified health centers, Family Heath Centers and Park DuValle.
Marketed as Care Connection, Passport places a nurse case manager at the heart of its plan to better coordinate care from the point of diagnosis of a potentially terminal illness, to help patients move efficiently from curative care to palliative-curative care to hospice care. The philosophy boils down to the notion that if a payer can provide the patient and family with information, support, and care, then when it comes time for the family to make a choice about continuing with curative care in the face of the inevitable or choosing hospice sooner when the benefit is best realized, hospice will likely be the choice.
Saving money through pain management
While nurse managers are nothing new to the health insurance industry, Passport’s system is different from the cost-conscious case managers traditionally associated with HMOs, says Marilyn Berwick, BSN, CCM, case manager with Passport Health Plan. Rather than focusing on keeping HMO costs down, officials say cost savings will be a by-product of providing better care.
"What we anticipate is fewer acute care episodes," says Berwick. "We also hope to see a reduction in the need for unnecessary emergency room visits through better pain management."
The idea to use case managers in end-of-life care was conceived two years ago at Passport, but Care Connection has just begun taking patients. The years following the idea included funding from the Robert Wood Johnson Foundation and planning research strategy to measure how the Care Connection approach affects patient care, whether it shortens hospital length of stay, and whether hospice lengths of service increase.
Researchers at the University of Louisville will study the progress of Passport’s approach. Specifically, researchers will study patient quality of life, functional status, patient and family satisfaction, physician satisfaction, hospital length of stay, and hospice length of service
"We spent the last year looking at our data, including the prevalence of cancer and other diseases and the practice patterns for treating those diseases," says Ruth Atkins, BSN, MA, director of quality and medical management for Passport. "Through this we were able to narrow our focus to patients with lung cancer."
Because of the high prevalence of lung cancer in the area due to the widespread use of tobacco, Passport officials and researchers decided that those patients presented the largest population of people at risk of not receiving palliative care when needed and not receiving hospice care in a timely fashion.
Passport leaders say its Care Connections program will focus on two major clinical initiatives: urging supportive care for patients earlier in their disease course and coordinating the care of diverse providers and caretakers. By using a case manager, Passport officials hope to introduce palliative care and other services earlier in the disease process, recognizing that many patients need pain management from the point of diagnosis.
Because many palliative care services are provided by hospice, including pain management, patients are often excluded from this kind of care because a terminal diagnosis is required for reimbursement.
Passport’s goal is to use case managers as patient and family advocates rather than as guardians of protocols. Often vilified for placing the financial interests of their HMOs first, health plan case managers are frequently at odds with doctors and patients. Passport’s vision of a case manager, however, is more of a patient liaison who will meet with the patient and family to discuss care goals and explain services that are available throughout each stage of treatment.
No terminal diagnosis necessary
This will allow patients to access pain management or spiritual care, for example, while still undergoing curative treatment, such as chemotherapy. It also will help patients and family prepare for the inevitable when curative efforts fail.
Access to pain management begins when a patient is diagnosed with lung cancer. The case manager meets with patient and family to explain the program, and patients are given the choice to participate or to continue with a more traditional management of their disease.
If the patient agrees to enroll in the program, the case manager makes an initial home visit, that includes an assessment similar to a hospice home assessment. Included in the first visit is a discussion with the patient about the options available in the program, including caregiver support services, spiritual care, and community support services. In addition, case managers work with the patient’s treating physician on pain management issues.
"When people understand their options, they begin to understand it’s not an either-or situation," says Berwick. "They can get palliative care despite no terminal diagnosis."
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