This patient experience may sound familiar: A 89-year old man with chronic heart failure experienced five emergency room visits and five hospital admissions in one year before his condition worsened and he was intubated in the ICU. Prior to this, he had been seeing his cardiologist and primary care provider for adjustments to his medications, which he was unable to manage at home.
Fortunately, a vastly better approach known as in-home palliative care now exists to the benefit of patients, families and providers: This innovative system of interdisciplinary care identifies patients with serious or advanced illness earlier in the disease process and offers them seamless case management.
This combination of a medical home — a coordinated and family-centric model of care — and palliative care delivered in in the home setting includes advanced care planning, symptom management, as well as care for spiritual, social or psychological needs. This specialized model encourages providers and care teams to meet patients where they are — from the simplest to the most complex conditions.
Understanding the medical home concept
The term “medical home” was first introduced by the American Academy of Pediatrics in the 1960s. Today, the medical model of care has experienced widespread adoption in response to positive patient outcomes and incentives provided as part of the Affordable Care Act. In fact, there are over 12,000 practices with more than 60,000 clinicians that are recognized by the National Committee for Quality Assurance’s Patient-Centered Medical Home Recognition Program.
While the word “home” suggests a place, in the case of a medical home it refers to a model of care. A medical home is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. A growing number of health care leaders believe this model represents how primary care should be organized and delivered throughout the healthcare system.
Patients are treated with respect, dignity, and compassion, and strong and trusting relationships with providers and staff are better able to thrive with the medical home approach. Overall, the model aims to achieve primary care excellence so that care is received in the right place, at the right time, and in the manner that best suits a patient’s needs.
It’s important for skilled nursing leaders to first understand how the function of the medical home works relative to palliative care to appreciate the full extent of the combined value for patients.
How a medical home team works
The medical home team is led by a physician and may include physician specialists, nurse practitioners, pharmacists, social workers, nutritionists, therapists, home health aides and case managers, depending on the needs of the patient.
The team addresses the unique needs of the patient and family and will take culture and values into consideration when developing a patient-centered approach to care. The medical home team also coordinates care of the patient and family across the continuum, which may include specialty care, acute, post-acute and community-based care needs.
Coordinating the needs of complex patients can be challenging due to severe or multiple health conditions and functional limitations. These patients are more likely to go to hospitals, emergency rooms, and long-term care facilities, and to need more supportive services to help with activities of daily living or arrange for transportation. As a result, they are more vulnerable to fragmented care and “falling through the cracks.”
Palliative care and the medical home
Palliative care programs — specialized medical care for people living with serious or advanced illness — encompass a wide range of services including home care, day care, inpatient/outpatient units, hospital teams, and nursing home as required by patients with chronic diseases.
Palliative care is a specialty that is well designed to support a medical home, or act as a medical home for patients with complex needs who are experiencing serious illness. In some new and innovative models, it is provided by a team of palliative care specialists, including nurses, social workers and others who coordinate care, provide an extra layer of support and communicate directly with the medical home physicians. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment.
Palliative care specializes in symptom management, medication management, completing advance directives and documenting goals of care. The good news is that expansion of the Palliative Medical Home is beginning to occur across the country, and some payers are in the process of developing a Palliative Care Medical Home.
SNFs and the medical home
As the medical home model of care expands, skilled nursing facility providers can expect to engage with case managers associated with medical homes who are coordinating with the patient and family through transitions from the hospital, to the skilled nursing facility to home.
Medical home case managers can be a valuable resource to the skilled nursing facility team by sharing pertinent patient information such as advance directives that could prevent an unwanted treatments and re-hospitalizations. They are also of tremendous value to social workers at skilled nursing facilities during the discharge planning process because they coordinate community-based services to successfully support the patient and family when returning to the community.
This is particularly relevant, since according to the most recent data, 23.5% of patients discharged from acute care hospitals to skilled nursing facilities were readmitted to the hospital within 30 days, at a financial cost of $10,362 per readmission or $4.34 billion per year. Seventy eight percent of these readmissions were labeled avoidable. More recent evidence suggests that hospitalization rates for dual-eligible patients living in long-term care facilities decreased by 31% between 2010 and 2015.
Today a growing number of organizations view palliative care in the context of the larger continuum of care and are moving from a generalized approach to one that is far more targeted to the specific needs of individuals with a serious or advanced illness.
As for the 89-year-old man with congestive heart failure, this new approach would have informed providers he did not want to go to the hospital or have intubation. When his health deteriorated, his social worker would have met with him and his family to discuss palliative care and supportive care options. He would have also been placed on the palliative care program with home visits made by palliative care specialists as needed. When the time came, his palliative care specialist would have evaluated hospice options with the patient and his family, and he would have died in the manner of his choosing — peacefully at home.
As the medical home model matures to include palliative care options, healthcare leaders are recognizing the value of innovative, specialized solutions that can help to identify, engage and improve patient and caregiver quality of life. Some new programs offer experience and background in serious illness and end-of-life care, and are specially designed to extend the reach of physician practices and the medical home. These select program provide the practical support that complements and enhances care management.
What is so valuable is that this new approach meets patients in the right place and at the right time, providing supportive home-based assessments and interventions and communicating relevant information to the primary treating physician / medical home. Collectively, these initiatives foster better communication to ensure that care delivery is consistent with individual patient goals of care.
Cyndi Seiwert is the Chief Operating Officer at Turn-Key Health.