Population Health and Health Plan Resources
Organizations working to improve the quality and efficiency of care must focus on the needs of the population living with serious illnesses. This palliative care toolkit is a collection of practical tools to identify, risk-stratify, and meet those complex needs.
What’s in the Toolkit
Comprehensive Guidance
Best practices for systematically improving value in the care of people living with one or more serious illness, gleaned from health systems, health plans, and accountable care organizations (ACOs) from across the country. The approach includes proactive patient identification, risk stratification, effective patient engagement and care planning, training and equipping the provider network to meet patient and family needs, and implementing appropriate quality measures and incentives.
A summary of implementation best practices for health plans and ACOs driving value in the care of high-need, seriously ill populations.
Identifying patients with frailty who are at high risk for health care utilization and adverse outcomes.
A summary of do's and don'ts for serious illness care across four key strategies. CAPC and Better Care Playbook
Case Studies
Learn from early adopters and jump-start population management efforts using recommended methods for patient identification, risk stratification, assessment, case management, and quality measurement.
ProHealth, a multi-specialty physician practice ACO, uses home palliative care for high-need patients.
Sharp Healthcare, an integrated network of hospitals and clinicians, incorporates a home palliative care intervention to meet the needs of complex patients.
Training complex case managers in communication skills and deprescribing. CAPC and the Accountable Care Learning Collaborative.
Use of palliative care-trained social workers to improve primary care for people living with serious illness. CAPC and the Accountable Care Learning Collaborative.
Use of screening to risk-stratify patients for palliative care based on need. CAPC and the Accountable Care Learning Collaborative.
OSF, a large, faith-based health system, implements a systemwide Advance Care Planning Initiative. CAPC and the Accountable Care Learning Collaborative.
Mercy Health, a 135,000 lives ACO, added in palliative care consultations virtually to the top 5% of its virtual complex care patients.
Anthem, a health plan operating across 14 states, includes palliative care structure and process measures in its quality incentive program for network hospitals.
Partnership Health plan, a regional plan in California, uses a small set of outcome measures in its contracts with palliative care programs.
A document detailing how Hudson Headwaters, a rural ACO covering 125,000 lives, deployed competent communicators to network facilities to significantly reduce avoidable hospital transfers.
A document detailing how Dean Health Plan, a large HMO in the midwest, successfully identified and engaged members in goals of care and advance care planning conversations.
An excerpt from CAPC's Home-based Guide, at-a-glance review of program models.
Trinity Health's journey to expand access to specialty palliative care across settings, and train all clinicians to identify and address sources of suffering for patients with serious illness.
An analysis of a health plan-led program of communication interventions and connection to palliative care and hospice, resulting in a significant decline in acute care utilization (Baquet-Simpson et al.).
Additional Resources
Additional resources to use when integrating palliative care into population management at your health system.
Structures and processes that all hospitals and skilled nursing facilities need to assure access to high-quality care for people with serious illness.
Toolkit for finding the right patients at the right time to address gaps in care.
CAPC has convened Medicare Advantage and ACO organizations for an in-depth learning experience on the four Serious Illness Strategies.
An adaptation of Ariadne Conversation Guide to build into a health system EMR. Ariadne Labs and Integra ACO.
