Although legislators have shifted pressure away from repealing the Affordable Care Act (ACA), many components of the nation's healthcare system — including accountable care organizations (ACOs) or integrated delivery networks (IDNs) still face a daunting challenge.

By 2050, the senior population is projected to grow by 135 percent, and the population aged 85 and over the group most likely to need health and long-term care services is projected to increase by 350 percent. Furthermore, the Department of Health and Human Services reports that care for the one-quarter of Americans with multiple chronic conditions accounts for about 66 percent of the country's total healthcare spending.

Numerous managed care organizations (MCOs) in the healthcare ecosystem are actually redoubling their efforts to identify and implement solutions. A growing priority is to optimize existing population health management (PHM) solutions by integrating community-based palliative care within the PHM framework.

With a focus on advanced illness and the introduction of services led by nurses and clinical social workers now recognized as palliative extensivists (PEs) organizations can leverage innovative PHM solutions to meet the needs of the whole person and caregivers, improving quality of life for all.

Innovative new model of palliative care

Successful models require clinically-driven programs, the proper infrastructure, staffing and resources to prevent negative quality and cost outcomes for members facing an advanced illness.

One new and innovative solution meets this challenge by delivering highly structured and consistent clinical programming in combination with quality monitoring and oversight. It's a unique PHM model that moves away from a generalized to a person-centric approach, with emphasis on solutions that meet the specific challenges of those members (and their caregivers) facing serious illnesses.

This structured, uniform approach to this defined population is what sets this model apart from any other palliative care PHM program on the market today.


The model begins by utilizing sophisticated analytics to identify members who are high opportunity not simply high cost in advance of the last six months of life. This identification occurs before the member receives nonbeneficial treatment, resulting in overmedicalized deaths, which are marked by costly hospitalizations and short stays in hospice, if at all.

This new model then takes a most important step. It convenes community-based teams comprised of palliative extensivists (PEs): specially trained nurses and social workers who typically exist within local hospice and palliative care organizations. These teams document member engagement/assessment activities in a palliative platform and follow structured risk-based care pathways and care management protocols.

The PEs utilize both telephonic and in-home questionnaires to perform and document initial and follow-up member assessments. The team reviews symptoms, performs medication reconciliation, and discusses and documents goals of care. They guide advance care planning, provide psychosocial support and identify caregiver needs.

These clinicians then create a palliative plan of care based upon member goals, while providing ongoing support for enhancing home support, educating members and assisting with member decision-making.

Scalable solution drives positive outcomes

Consider the results of a one-year program that tested and validated PIM for seniors enrolled in a Medicare Advantage plan. There were 208 members enrolled in the program, compared to 800 members who were identified by the model but not enrolled. The overall reduction in healthcare expenditures was 34 percent:

  • Lower hospitalizations: 32 percent
  • Reduced hospital readmissions: 61 percent
  • Reduced ICU days: 37 percent
  • Earlier and appropriate election of the Hospice Medicare benefit

Results from the program also demonstrated impressive clinical results:

  • 98 percent goals of care completion
  • 97 percent symptom satisfaction
  • 4.8/5 stars satisfaction rating

This extraordinary level of personalized support aligns physicians and other care teams to organize member care and create seamless transitions in care that directly achieve safer, more effective outcomes. PEs aim to keep members healthier outside the hospital, providing regular, routine home visits and phone outreach that reduces emergency room visits, hospitalizations or readmissions and ICU stays.