Designing Community-Based Palliative Care

A Guide for Payers

In 2010 and 2011, health insurance companies across the country began developing pilots for Palliative Care Services. Through these pilots, case managers realized that the patient population needs defined services rather than solely telephonic support and advance care planning. Implementing community-based palliative care (CBPC) became a priority. These community-based palliative care initiatives began strategically with the expectation and understanding that it would grow to be system-wide and within all product lines, or lines of business. To assist in initiating these programs in California, health plans and various provider partners utilized planning and implementation grants from the California Health Care Foundation to implement pilots in 2016. Later, the same health insurance companies, through system partnerships, piloted palliative care with an Accountable Care Organizations (ACO). These pilots enabled health plans and partners to incorporate the CBPC model within a delegated risk arrangement and create clinical workflows that originated with primary care providers and health system case managers. Eventually, in California, it led to statewide adoption of community-based palliative care services through SB1004, requiring the provision of these services by all managed Medicaid health plans. Payers concurrently rolled-out a state-wide expansion of CBPC, the approach of which will be further informed and discussed throughout this toolkit

Outcomes

The aforementioned health insurance companies, through the creation of the California Advanced Illness Collaborative (CAIC), developed a balanced scorecard to report how their community-based palliative care programs aligned with company goals and the Triple Aim in Healthcare, incorporating Utilization, Clinical Quality, and Satisfaction/ Experience measures. These also included a measure demonstrating goal-concordance, in line with the goals of members who have a completed advance health care planning document or other demonstration of discussion about goals for care.

Utilization of Serious Illness Management Services

More than 3,000 members – as well as their families and caregivers – received community-based palliative care services through CAIC-affilia

ted health insurance companies specific health plans to date, nearly double the number at the implementation of SB1004 in 2017. Patient and Family Satisfaction Community-based palliative care programs received an average patient and family satisfaction score of 95% Goal Concordant Care A 2012 study found 70% of Californians would prefer to remain in their homes: however,
only 32% of all Californians passed away at home. This is similar to the national average, according to a poll conducted by the Cambia Health Foundation in 2011. Conversely, 90% of the health insurance companies’ members enrolled in palliative care who have passed away did so in accordance with their wishes to be in their homes at the end-of-life Increased Benefit Utilization Members referred to palliative care were more than twice as likely to utilize their hospice benefits when compared to the national average.

Intent

The focus of this toolkit is on the decisions, questions, and considerations that go into designing and implementing a community-based palliative care program from a payer’s perspective. The information presented in this toolkit is based on the valuable insights and lessons learned from a health insurance company’s experience, which ultimately led from a pilot to an operational state-wide program.

Content

The process for developing a program is iterative. It requires input and assistance from multiple departments throughout an organization, as well as external partners and stakeholders, including patients and families. The various phases undertaken throughout community-based palliative care design and implementation have been used to organize this toolkit. Insights into such a journey are included where applicable throughout the toolkit to provide valuable examples and illustrations.