Editor’s Note: This post is the second in a periodic Health Affairs Blog series on palliative care, health policy, and health reform. The series features essays adapted from and drawing on an upcoming volume, Meeting the Needs of Older Adults with Serious Illness: Challenges and Opportunities in the Age of Health Care Reform, in which clinicians, researchers and policy leaders address 16 key areas where real-world policy options to improve access to quality palliative care could have a substantial role in improving value. This post describes the Advanced Care model, a delivery system approach that includes palliative care and coordinates services for people with serious chronic illness across hospitals, medical groups, homes, and the community.
Like other initiatives to reform American health care, the movement to improve care for patients with advanced illness does not suffer from a lack of new ideas. The real barriers to improvement lie in replicating innovative models that have already addressed the problem and found scalable and sustainable solutions. Fortunately, promising initiatives are now prepared to transform care on a national scale. These developments are timely because reform is badly needed.
Our fragmented approach to advanced illness exacts a terrible toll from our sickest and most vulnerable citizens and their families. It also places a growing burden on our health care system. Hospital treatment of advanced illness absorbs a large fraction of the Medicare budget. Over one quarter of all Medicare expenditures pay for care in the last year of life, a proportion that has not changed in 35 years. CMS research shows that about 30 percent of this final-year spending is concentrated in the month prior to death, and 80 percent of Medicare dollars spent during that final month go toward hospital treatment.
People suffering from advanced illness — multiple chronic conditions with declining function and poor prospects for full recovery — often fall through the cracks between current programs and providers. Like patients under disease management, people with advanced illness have multiple chronic conditions, but their decline in health and function is more pronounced, faster, and in many cases irreversible. In short, a person with advanced illness has entered the “gray zone” between treatable and terminal illness.
Most of these people are not yet eligible for hospice, and many are reluctant to become “hospice patients.” For these and other reasons, hospice is often not used as effectively as it might be. Thus, although it was conceived as an alternative to hospitalization, hospice today often amounts to a brief final addendum to a long siege of aggressive inpatient care.
Clinical innovation and federal policy initiatives may soon transform care for this population. The Advanced Care model described here promotes personal dignity and choice, moving care for advanced illness out of hospitals and into homes and the community (Note: This post describes the Advanced Care model, a delivery system approach that includes palliative care and coordinates services for people with serious chronic illness across hospitals, medical groups, homes, and the community). In support of this and similar models, a thoughtful and substantive dialogue is emerging in federal public policy.
The Advanced Care Clinical Model
The Advanced Care model integrates care across multiple dimensions. A “team of teams” approach coordinates care across clinical settings and over time. Specially trained, physician-directed interdisciplinary teams are placed in hospitals, physician practices, homes and the community. These teams connect with patients, families and each other in real time through electronic health records (EHR) and sophisticated telephone management.
Key attributes of the Advanced Care model include:
- Prioritizing personal values, goals, and preferences as drivers of care, rather than clinical urgency and crisis.
- Placing the focus of care at home, whether personal residence, long-term care, or homeless shelter. This promotes self-management, anticipates crises, and prevents hospitalization.
- Extending palliative care, an important component of Advanced Care, into home and community, managing symptoms and suffering and supporting advance care planning over time at the ill person’s own pace, in the safety and comfort of home.
- Fostering better use of hospice, increasing enrollments and, where appropriate, earlier entry into hospice.
- Empowering the personal physician to guide a team of critical allied professionals such as nurse practitioners, physician assistants, nurses, social workers and others. This approach mitigates workforce challenges by leveraging scarce geriatrician, palliative care, and primary care physician time and expertise through teamwork. Advanced Care-type teams are instrumental to medical homes that achieve savings.
- Integrating care across acute, post-acute, and long-term care settings into a coherent, operational whole, preparing disparate hospitals and provider groups to work with private health plans and Medicare to provide accountable care-based solutions. This creates an infrastructure that can later be extended from advanced illness to less severe chronic diseases.
- Preparing for population management. As the U.S. health system moves from fee-for-service to shared risk/shared savings reimbursement, organizations engaged in accountable care could join forces with local government, public health and social service agencies, voluntary groups, faith-based organizations and others to reduce unwanted emergency visits and hospitalizations.
Advanced Care’s dignity-driven approach pays off in savings to Medicare. Research published by the Agency for Healthcare Research and Quality and in journals such as Health Affairs and the Cleveland Clinic Journal of Medicine have found that prototypes like Aetna’s Compassionate Care® and Sutter Health’s Advanced Illness Management (AIM)® achieve savings of over $2,000 per program enrollee per month, with excellent patient, family and physician satisfaction scores. Savings are produced, not by cutting or denying services, but by providing a new kind of care management to ensure that personal choice drives treatment.
Toward A National Model
Stakeholders and innovators in the private sector and bipartisan members of both houses of Congress have sparked a national dialogue to create a new foundation for federal policy. Collaborations between stakeholders and efforts by congressional committees and members of congress from both parties have produced significant federal legislative initiatives. These bills emphasize voluntary conversations between health care professionals and patients about values, goals and preferences of care, greater funding for workforce development, and test comprehensive models of advanced illness care focused on coordination and integration of services. CMS has also signaled interest through the Center for Medicare and Medicaid Innovation (CMMI), providing $13 million to test Sutter Health’s AIM® program in the first round of Health Care Innovation Awards.
Partnerships among multiple private-sector stakeholders have fostered path-breaking coalitions of consumers, providers, health plans, and national innovators. A leading example is the Advanced Care Project (ACP), a partnership between the Coalition to Transform Advanced Care (C-TAC), representing over 100 national organizations dedicated to improving care for those with advanced illness, and the AHIP Foundation’s Institute for Health Systems Solutions. The ACP is designed to develop, evaluate, and implement national clinical and payment models for advanced care. Phase I of the project develops a best-practice-based framework, along with complementary payment methods, to align incentives and share best practices among emerging clinical models. Phase II establishes a national multi-site demonstration to build out the evidence base and further evaluate what interventions work best in different communities and clinical settings. Phase III, to run in parallel with the other phases, focuses on replication and rapid-cycle deployment.
Early evidence suggests that the Advanced Care model may improve care for people with serious chronic illness by prioritizing personal values, goals, and preferences and shifting the focus of care from hospital to home. Substantive dialogue and partnerships have emerged at federal and private sector levels to support and test this intervention. This constitutes a unique opportunity for positive change in the way we respect and care for those with advanced illness, as well as their families and caregivers.