Home-Based Palliative Care: There’s Never Been a Better Time

The Affordable Care Act (ACA) opened doors for community-based palliative care – but what, specifically, does that mean for providers who want to start a program that serves patients outside of hospital walls?

The ACA initiated and/or accelerated a variety of changes to the way health care is reimbursed, and placed the emphasis on value instead of volume – high-quality care that meets people’s needs without unnecessary costs. The result is a dizzying array of new payment mechanisms and entities (e.g. risk-sharing, bundled payments, ACOs and capitation, to name a few). A thorough treatment of these payment models is beyond the scope of this blog post, but this white paper by HCP-LAN is a very helpful reference on alternative payment models, and a good place to start.

The net impact for community palliative care boils down to this: the program that demonstrates value (better quality at lower cost) has better opportunities for reimbursement than ever before.

The impact of this shift toward value is particularly clear when viewed through the lens of home-based palliative care. Palliative care can provide critical support for seriously ill patients who are not eligible for the Medicare hospice benefit (for example, patients who continue to benefit from disease treatment). However, in the fee-for-service world, the home-based palliative care program cannot offset its costs by fee-for-service billing alone. Drive time for clinical staff, the time-consuming nature of the work itself and the central role of (non-reimbursable) nursing and social work services in community care delivery means that home-based palliative care requires additional financial support to survive. Historically, few health systems or community organizations have funded such services.

Fast-forward to 2016. Health systems and other provider organizations are increasingly accountable for measures such as 30-day readmissions and patient satisfaction. Fueled by data that demonstrate home-based palliative care outcomes that include both decreases in costly hospital utilization and improvement in patient and family experience, forward-thinking systems have taken notice. A growing number of hospitals, hospices, home health agencies and group practices now offer home-based palliative care as a separate business line for patients in their communities.

Last spring, CAPC convened a workgroup of eleven home-based palliative care programs that represent a variety of organizational homes (health systems, hospices, home health agencies and the VA) and a range of program models and funding sources. Our goal was to begin the process of identifying what works, and what doesn’t, for developing sustainable home-based palliative care programs. A central theme that emerged from the group is that in this brave new world of alternative payment, understanding program costs and measuring program impact is essential to financial viability.

For this post we’ve interviewed workgroup member, Dr. Amy Frieman, Medical Director of Palliative Care at the Meridian Health System in Neptune, NJ, to understand how her program approached the challenge of measuring value and proving impact.

This home-based palliative care program is one component of the Meridian Care Journey comprehensive palliative care program; Meridian Care Journey also provides palliative care in inpatient, skilled nursing facility and office settings. Meridian Care Journey is a CMS demonstration project. Teams of nurse practitioners, nurses, social workers and chaplains travel primarily to patients’ homes and also to subacute rehabilitation facilities and assisted living or long term care residences. Meridian’s home-based program is a consultative model that collaborates with primary and specialist care providers, focusing on improving quality of life for its patients through symptom management and psychosocial support. A per member per month reimbursement model supports the program.

CAPC: Did you do a needs assessment when you started your home-based program?

Dr. Amy Frieman (AF): We did a fairly extensive needs assessment. Working with our data analysts, we tried to identify the highest-cost, highest-acuity patients in our health system and that is the way we developed our qualification criteria. We looked at several years of data in order to make sure we were capturing the appropriate patients.

CAPC: How did those data get translated in eligibility criteria for the program?

AF: The way that our program is structured, a patient has to have a hospital discharge from within the health system, and we identified the MS-DRGs upon hospital discharge that represented those very sick, high risk patients and we built those into the eligibility criteria of the program. Along the way we realized that MS-DRGs alone did not capture every patient that we wanted. An example would be a patient with metastatic colon cancer who presents to the hospital with a bowel obstruction. His MS-DRG would have been coded bowel obstruction, and we would have missed that patient even though he was very appropriate for our program. Ultimately, we had to build ICD-9 codes (and later, ICD-10 codes) and comorbidities into our eligibility criteria.

CAPC: How did the home-based program start?

AF: Meridian wanted to apply for this particular demonstration, and I think they were really ahead of their time. The application was submitted in 2006, when there weren’t many people thinking about home-based palliative care. The administration was supportive of the idea for several reasons: it did address very high-cost patients, but we were also recognizing a gap in care in our system that we wanted to be able to fill.

CAPC: How is the home-based program financed, and does that differ from how Meridian’s inpatient service is financed?

AF: The home-based program is financed based on a per member per month care management fee. There is no billing at all currently in our home-based program. In the inpatient world, we bill fee-for-service for physician and nurse practitioner services.

CAPC: At startup, how did you decide which program metrics to track? Were you responding to your system administration and to the requirements of the CMS demonstration?

AF: We wanted to follow what guidelines were out there, so we looked at the National Quality Forum and at CAPC to figure out what we should be tracking. We also considered what we felt was important to our system and to our patients, so it was a combination of factors.

I think that it is incredibly important for a new program designing metrics to ask: What are the health system’s needs right now, and what is the health system trying to accomplish? Is it a move towards population health? Is it that they have patients with heart failure who are being readmitted? Build around what’s important to the stakeholders, because what you want to be measuring and collecting depends on what your stakeholders are trying to accomplish.

CAPC: What do you consider to be the most important measures that help you evaluate the impact of the program?

AF: The important measures are symptom assessment and intervention. We look at whether we actually conduct advance care planning: do we have documentation of those conversations? Do we have actual documents available in the medical record? If a patient doesn’t die on hospice, are we offering appropriate bereavement services? The patient-centered metrics are where we see whether the program really makes a difference for the patient. Satisfaction surveys also fall into this category. We’ve learned a great deal by looking at what patients and families believe we are doing well, and what we need to work on doing better.

CAPC: What tools do you use to collect patient satisfaction information?

AF: We send out a satisfaction survey to patients who have been enrolled in the program for 90 days. We then send it every 6 months to patients and their families.

CAPC: What are your key operational or process measures?

AF: Our demonstration contract requires that we touch every patient every month. When you’re talking about 1,800 patients, keeping track of those touches is extremely important. We also need an understanding of what percentage of our visits are face-to-face. The other thing is scheduling – figuring out how to get our clinicians out there in the field in a geographical area that makes sense and allows them to see the most patients. We cover two very large counties so we’ve been able to create zones that are covered by specific clinicians. Another important metric for us is transition to hospice: are we getting appropriate patients onto hospice, and are we increasing length of stay for our patients on hospice? Since we track those metrics, we know the answer is yes.

Our system leadership wants to see that we are improving quality and patient and family satisfaction. They are also interested in the number of ER visits , hospitalizations and readmissions and transitions to the system’s hospice.

CAPC: Have you needed to change anything about the way you’ve collected data since you started the program?

AF: We feel as a team that having a care planning conversation and documenting a patient’s wishes is equally important to having a physical document, whether it’s a healthcare proxy form or a POLST or another legal document. Figuring out how to make that work has been a bit labor-intensive but now we have questions about ACP on multiple encounter forms – it’s not just an initial home visit form, it’s our follow up form, our psychosocial form and others.

CAPC: Your program uses a stratification tool to determine the level of support needed for your patients. Can you tell me how that works?

AF: It’s based on multiple factors including comorbidities, performance status (we use the Karnofsky scale), ER visits and hospitalizations and also on self-report of physical symptoms. What we’re trying to do is figure out how sick a patient is, and what interventions are most appropriate. The clinicians always have the ability to modify the stratification as, over time, a patient’s illness progresses. For example, the stratification might change if a patient is admitted to the hospital or conversely, begins to get better and needs fewer resources from us. The process helps us to identify which services are needed and it also helps us determine how often our face-to-face visits occur versus comprehensive phone interventions.

CAPC: Do you think the program data you’re collecting now will help you secure funding once the CMS demonstration ends?

AF: Absolutely. What we’ve been able to accomplish has helped our hospital system believe that this needs to continue. Meridian has decided that they will fund a home-based program on an ongoing basis. It will initially not have the same scope as the current demonstration project, but we are also looking to work with our commercial payers and Meridian’s home care and hospice to continue to grow the program’s footprint. We are confident that this program will continue beyond the demonstration project based on the data we’ve collected.

CAPC: Are you able to share any of these outcomes from the program’s first few years?

AF: Our data will be communicated after the CMS demonstration project ends. I can say that our quality and satisfaction metrics have consistently been greater than 90%.

CAPC: Thank you Dr. Frieman – we can’t wait to learn more!

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Looking for tools specific to palliative care delivery in the home? Take CAPC's online course (and review the corresponding toolkit), Designing a Home-Based Palliative Care Program, and earn free CEs and ABIM MOC points.

For tools and resources for the community-based palliative care program, click here.

Not a member? Visit www.capc.org/membership to learn more about the benefits of CAPC membership.