critical pathways to improved care for serious illness

Critical Pathways to Improving Care for

Serious Illness

Roundtable Discussion on Care Model FrameworkMarch 10, 2017

Petrie-Flom/ C-TAC Project on Advanced Care and Health Policy

Funded by the Gordon and Betty Moore Foundation

Petrie-Flom / C-TAC Project on

Advanced Care and Health Policy Collaboration between C-TAC and the Petrie-Flom Center for

Health Law Policy, Biotechnology, and Bioethics at Harvard Law School

Launched in 2016 to “foster development of improved models of care for individuals with serious advanced illness nearing end-of-life, and to apply interdisciplinary analysis to important health law and policy issues raised by adoption of new person-centered approaches to care for this growing population”

C-TAC thanks Petrie-Flom and project partners:

Healthsperien

The Betty Irene Moore School of Nursing at UC Davis

The Center to Advance Palliative Care (CAPC)

Kathleen Kerr

Gordon & Betty Moore Foundation

Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 2

Project Objectives

Develop a flexible serious illness care model implementation framework within a 6-months timeframe

Framework establishes the context for how consideration of evidence fits into the design of a serious illness program

Framework should identify common program elements but recognize the need for local variation in program design and implementation related to factors like payment model, internal capabilities, care setting, etc.

Framework purpose:

Inform serious illness program development, replication, and scaling

Integrate with care model payment design

Inform care model Proforma simulator development

Inform other aspects of design and development such as policy, standardized measurements, and regulatory analysis


Framework Objectives

Understand the range of population needs

Identify promising solutions

Elevate core care outcomes

Analyze implementation considerations

Evaluate evidence


Today’s

Session

Next

Steps

Agenda 10:30-10:50am, Introduction and Overview

10:55-11:00am, Why Develop an Implementation Framework?

11:00-11:30am, Discussion of Current Programs and White Papers

11:30-11:50am, Serious Illness Care Model Framework Objectives

11:50am-12:00, Audience Q&A

12:00-12:30pm, Lunch/Networking

12:30-2:00pm, Discussion of Serious Illness Care Model

Overarching Model

Population

Solutions

Goals

Next Phase of Work: Implementation Roadmap Design

2:00-2:30pm, Conclusion and Q&A


Convening Session Panelists

Panelists

Namita Ahuja MD, Sr. Medical Director, Medicare, UPMC Health Plan; Clinical Assistant Professor of Medicine, University of Pittsburgh

K. Eric De Jonge MD, Director of Geriatrics at MedStarWashington Hospital Center; Associate Professor of Medicine, Georgetown University School of Medicine

Timothy Ferris MD, MPH, Senior Vice President of Population Health Management, Partners HealthCare and Mass General Hospital

Muriel Gillick MD, Director, Program in Aging, Harvard Pilgrim Health Care Institute and Professor of Population Medicine, Harvard Medical School

Anna Gosline SM, Senior Director of Health Policy and Strategic Initiatives, Blue Cross Blue Shield of Massachusetts

Lauran Hardin MSN, RN-BC, CNL, Senior Director Cross Continuum Transformation, National Center for Complex Health and Social Needs, Camden Coalition of Healthcare Providers

Emma Hoo, Director, Pacific Business Group on Health

Sally Okun RN, MMHS, Vice President, Advocacy, Policy, and Patient Safety, PatientsLikeMe

Russell Portenoy MD, Chief Medical Officer, MJHS Hospice and Palliative Care; Executive Director, MJHS Institute for Innovation in Palliative Care; Professor of Neurology and Family and Social Medicine, Albert Einstein College of Medicine

Monique Reese DNP, ARNP, FNP-C, ACHPN, Chief Clinical Officer, Sutter Care at Home

Jennifer Valenzuela MSW, MPH, Principal of Program Department, HealthLeads

Project Partners

Robin Whitney PhD, Assistant Professor, University of California San Francisco School of Medicine*

Kathleen Kerr, Healthcare Consultant, Kerr Healthcare Analytics*

Allison Silvers MBA, Vice President, Payment and Policy, Center to Advance Palliative Care (CAPC)*

Janice Bell PhD, MPH, MN, Associate Professor at the Betty Irene Moore School of Nursing, University of California, Davis

C-TAC and Healthsperien

Tom Koutsoumpas, Co-Founder and Co-Chair, Coalition to Transform Advanced Care (C-TAC)*

Khue Nguyen PharmD, Chief Operating Officer, C-TAC Innovations*

Gary Bacher JD, MPA, Founding Member of Healthsperien, Co-Director, Smarter Healthcare Coalition*

Mark Sterling JD, MPP, Senior Fellow, Project on Advanced Care and Health Policy, Petrie-Flom Center at Harvard Law School; Chief Strategy Officer, C-TAC Innovations*

Jon Broyles MS, Executive Director, C-TAC

Theresa Schmidt MA, PMP, Vice President of Strategy, Healthsperien; Director of Data and Quality, National Partnership for Hospice Innovation

Brad Stuart MD, Chief Medical Officer, C-TAC

David Longnecker MD, Chief Clinical Innovations Officer, C-TAC

Nick Martin Director, Communications & Outreach, C-TAC

Sibel Ozcelik ML, MS, Research and Implementation Coordinator, C-TAC


*March 10 Presenters

Opportunity:From Innovation to Implementation

Where do you start?

Which care model do you use?

How does your effort relate to others?


Serious Illness Landscape

White Papers & Care Models

UC Davis School of Nursing, Kathleen Kerr, CAPC


Serious Illness Care: an Overview of Existing FrameworksROBIN L. WHITNEY, PHD, RN

White Paper Scan

Organizations Terminology Identification Components

Providers OutcomesPayment Models

CRITICAL PATHWAYS TO IMPROVING CARE FOR SERIOUS

ILLNESS10

White Paper Author OrganizationsCoalition to Transform Advanced Care (C-TAC)

Health Care Transformation Task Force (HCTTF)

Center to Advance Palliative Care (CAPC)

Common Practice

Institute for Healthcare Improvement (IHI)

The Conversation Project (TCP)

RAND Health

American Hospital Association (AHA)

National Academy of Social Insurance

National Consensus Project for Palliative Care

SeniorBridge

Agency for Healthcare Quality and Research (AHRQ)

Mathematica

Robert Wood Johnson Foundation (RWJF)

Center for Health Care Strategies

Health Industry Forum

National Academy of Medicine


ILLNESS11


ILLNESS12

Terminology


ILLNESS13


ILLNESS14

Patient Identification

Expert Opinion

Quantitative Algorithm

Optimal


ILLNESS15

Common Triggering CriteriaAdvanced Cancer

DementiaDiagnoses

Serious Mental Illness

Cognitive ImpairmentBehavioral Health

Assistance with ADLs

Caregiver BurdenFunctional Impairments

Poverty

Access to CareSocial Vulnerability

Palliative Care

HospicePrognosis

Prior Use and Costs

Risk Screening: “Would you be surprised?”Risk


ILLNESS16

Program Components

Comprehensive Assessment

Advance Care Planning

Care Coordination

Symptom Management

Self-Management

Support

Caregiver Support

Spiritual Support

Home-Based Care

Workforce Training


ILLNESS17

24/7

Technology

Enabled

Concurrent with Active Treatment


ILLNESS18

Care Providers

Patients Caregivers

Interdisciplinary

Teams


ILLNESS19

Team Composition

Registered Nurses

Physicians

Pharmacists

Lay Health Workers

Behavioral Health

Chaplains

Social Workers

Core Palliative Care Skills


ILLNESS20

Outcomes

Utilization

• ED visits

• Inpatient Admissions

• ICU stays

Costs

• Total Spending

• Cost-benefit analysis

Process Measures

• Documentation of ACP discussion

• Completion of pain assessment

Patient Reported Outcomes

• QOL

• Satisfaction with care


ILLNESS21

Payment Structures

Shared Risk/ Shared Savings

Value or Population-

Based

Strategies in FFS Models


ILLNESS22

Observations on current efforts to provide quality serious illness care

Kathleen Kerr

[email protected]

415-439-9789

mailto:[email protected]

Objective

Observations culled from…• Multiple CHCF initiatives related to community-based PC

– Payer-provider partnerships– Expanding access to PC in safety net systems– Expanding access to PC in rural areas– SB1004 implementation support

• GBM assignment– Identification of 100 serious illness programs– 14 case profiles

• Mr. B

Share observations about the current state of serious illness care, to inform improvement efforts


Serious Illness24

Patient population for GBM work

• Poor prognosis and are likely in the last stage of life (which could last for years)

• Experience functional impairment

• At risk for cycling in and out of the hospital in absence of additional supports


Serious Illness25

Essential (ideal) elements of serious illness programs

Team-based approach

Goal-based approach

Concordant care

Comprehensive care

Coordinated services

Transition supports

Home-based care

Rapid access to services

Family-oriented care

Caregiver support

Measurement


Serious Illness26

Core (observed) serious illness program services(in addition to concurrent access to disease-directed care)

1. Pain and symptom management

2. Medication management and reconciliation

3. Medical information / prognostication support

4. Goals of care & advance care planning discussions, and assistance with documentation

5. Case management / care coordination

6. Transition support

7. Psycho-emotional support for patients

8. Emotional support for family caregivers

9. Spiritual care

10. Referrals to community resources for assistance with social and practical needs (or provide such services directly)

11. 24 / 7 service or strategies to ensure expanded access

12. Bereavement support or referrals

27Critical Pathways to Improving Care for

Serious Illness

1. Several types of organizations sponsor serious illness programs

Health systems

Medical groups

Health plans

Hospice & PC organizations

Specialty organizations

Partnerships


Serious Illness28

2. Core services offered via a wide range of interventions

Home-based primary care

Specialty geriatric services

Specialty palliative care

Specialty care units

Care management

services

Navigation / coaching programs

Transition management

programs

Structured ACP programs

Social supports and services

Spiritual care programs

Support programs for families /

caregivers

Complementary and integrative

medicine services

Hospice


Serious Illness29

3. Variation abounds (which might be OK)

• Eligible/target patients• Strategies for identifying patient population• Scope of service• Care settings• When engage, frequency of contact, length of service• Staffing (which disciplines) and staffing ratios• Training requirements• Use of lay staff and volunteers• Degree of integration with primary / specialty services

(referring providers)• Metrics• Payment models and payment amount• Number of customers


Serious Illness30

4. Common to offer a suite of services

31


Serious Illness32

System-based programs cross settings and service lines

AllinaHealth Abbott Northwestern Hospital – Minneapolis

Full array of primary and specialty services, home health and case management plus …• specialty palliative care available in multiple settings• embedded specialty geriatric care in transitional care units, nursing

homes and assisted living communities• medical home for individuals with complex conditions• advance care planning classes offered at multiple clinics• lay navigator program (LifeCourse)• hospice care

Variation across markets, campuses within markets, and

accessibility depending on disease, age, insurance


Serious Illness33

Multi-organization efforts are common

• Funding, plus support from Clinical Analytics, Case Managers, Social Workers, pt transportation costsHPSJ

• Primary and specialty care, plus inpatient and clinic-based palliative care

San Joaquin General Hospital

• Home-based palliative care, with ability to transition to hospice as appropriate

Community Palliative & Hospice Care

• Home-based palliative care, with ability to transition to hospice as appropriate Hospice of San Joaquin

• Telephonic case management, analytics to identify patients, and "feet on the street" (member engagement)Axispoint Health

• Mental health servicesBeacon Behavioral

Health

Multi-organization network for a rural, poor county


Serious Illness34

5. Safety-net programs have distinct challenges


Serious Illness35

Palliative care focus areas

Patient

& Family

Symptom

Manage-ment

Info about Prognosis,

Options

Assess Values & Translate

into Medical Choices

Spiritual support

Psycho-social

support


Serious Illness36

Patient

& Family

Symptom

Manage-ment

Info about Prognosis,

Options

Assess Values & Translate

into Medical Choices

Spiritual support

Mental Health Care

Companionship

Caregiver issues

Access to food

Transportation

Housing & Physical safety

Legal support

Financial support

Safety-net palliative care focus areas


Serious Illness37

6. Rural programs have distinct challenges

• Distance / geography

• Less than optimal voice / data connectivity

• Opioid epidemic / other substance abuse

• Poverty

• Older, isolated population

• Few available providers

#1

#2

#3

Total travel time between visit 1-2

and visit 2-3 = 4 minutes

Implications for ….

• Clinical model / scope

• Staffing-training /

partnerships

• Caseload

• Cost of care, potential impact


Serious Illness38

7. Multiple funding options … but not universally available

• Support from parent organization (quality/operational value, loss leader, mission)

• Traditional FFS billings

• Hospice benefit

• Health plan contracts (multiple business lines)

• Serve MA/ MA SNP / Medicaid Managed Care population

• Serve ACO population (Medicare and commercial)

• Serve global/full capitation population (PACE)

• CMS demonstrations/Innovation programs: IAH, Oncology Care Model / ESRD Care Model, CCTP, MCCM, CPC+

Terrific reference: CAPC’s Payment Primer: What to know about payment for

palliative care delivery (https://www.capc.org/topics/payment/)


Serious Illness39

8. Funding doesn’t solve all problems

• Workforce – “It has been difficult to achieve rapid scale of our model

and ramp up services to cover a larger geography. Workforce shortages and competition in the market for talented palliative care providers continues to be a challenge.”

• Rescue and repair– “About 90% of patients referred to Transitions do not know

that their diseases are terminal.”

• Willing referring providers– “Let’s see what the cath results are and if there is nothing

more we can do then I’ll refer to palliative care”

• Willing patients– Must be … open to more support, open to strangers in the

home, able to get to clinic, can afford co-pays, etc.


Serious Illness40

Dying in America: Improving Quality and Honoring

Individual Preferences Near the End of Life

IOM (Institute of Medicine). 2014. Dying in America: Improving quality

and honoring individual preferences near the end of life. Washington,

DC: The National Academies Press.

Turns out they were on to something …

Five improvement /focus areas1. Delivery of person-centered, family-

oriented EOL care2. Clinician-patient communication and

ACP3. Professional education and

development4. Policies and payment systems5. Public education and engagement

Food for thought

1. Many types of providers / sponsors … consider getting input from all

2. Range of patient and family needs/preferences requires a suite of interventions … not just one thing, and often not just one organization

3. There are particular challenges when delivering care in the safety-net and to rural populations; these may impact staffing and training, care model, program costs, expected impact, and more

4. Some success with existing funding options, but program scope and design often limited by what gets paid for

5. Consider focus on integration / coordination / education as solutions to workforce issues, and to promote buy-in from patients and providers

6. While there are many challenges, there are also are many promising programs and practices operating currently (it’s probably okay to be a little optimistic)


Serious Illness42

Serious Illness

Care Model

Framework


C-TAC and Healthsperien

Framework Objectives

Understand the range of population needs

Identify promising solutions

Elevate core care outcomes

Analyze implementation considerations

Evaluate evidence


Today’s

Session

Next

Steps

Framework Design Considerations

Design to support implementation decision-making

See the universe through modular building blocks

Global view consists of “generic” high-level descriptors,

span across care models/patient care programs

Detailed view conveys range of operational

applications


Implementation Considerations


Population

Needs

Care

Management

Solutions

Serious Illness Program

Implementation PathCare

Outcomes

Payment

Model

Internal

Capabilities

Regulatory

Framework

Local

Context

Designing a Serious Illness

Program

Identify population

Identify core care outcomes desired

Match care management solutions population and outcomes

Assess available evidence

Identify context considerations

Develop implementation strategies


Defining Serious Illness

Population Needs


Self-rated health

Fair

Poor

Hospitalization Risks

Moderate

High

Decline Trajectory

Intermittent

Gradual

Active

Activities of Daily Living

Occasional Assistance

Frequent Assistance

Full Dependence

Care

Management

Needs

Low

Medium

High

Health Status

Coping Capability

(Self efficacy, support system, access, SES, mental health,

cognitive ability)

High

Moderate

Low

Coping StatusFunctional Status

Care Management Solutions


Care Management Interventions

Health Coaching and Care Coordination

Proactive Clinical/Symptom

Management

Comprehensive Advance Care

Planning

Resources

Lay Navigators

Care Management Clinicians

Providers

Mode of Delivery

Virtual (phone, video, sensors/ monitors)

Home

Physician office / clinic

Hospital

PAC/LTC facility

Frequency/ Duration

Episodic

Longitudinal

Care Outcomes

Health

Quality of Life

Maximized Functions

Aging in Place

Support

Patient/ Family Engagement

Self-efficacy

Care Concordance


Care

Manage-

ment

Needs

General Care Model

Development Pathways

51

Serious Illness Population


Health Coaching and

Care Coordination

Proactive Clinical/Symp

tom Management

Comprehe-nsive

Advance Care Planning

Resources

Lay Navigators

Care Management

Clinicians

Providers

Mode of Delivery

Tele-management

Home

Physician office / clinic

Hospital

PAC/LTC facility

Frequency/ Duration

Episodic

Longitudinal


Correlation

between

Parameters

Decline Trajectory

Functional /

Coping Status

Service Intensity

& Scope

Team Resources

& Home Support

Health Status:

Fair

Poor

Moderate

High

Intermittent

Gradual

Active

Hospital-izationRisks

Decline Trajectory

Self-rated Health

Functional Status:


Frequent Assistance

Full Dependence

ADLs

Coping Status:

High

Moderate

Low

Coping Capability

© 2017 C-TAC

Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC

General Characterization of Existing Care Models

52

Health Status* ADLs Coping Capability


Resources Mode of Delivery

Frequency/ Duration

Intermittent

Gradual

Active

High

Moderate

Low

Health Coaching & Care Coordination

Telemanagement

Home EpisodicHigh


Frequent Assistance

Full Dependence

Lay Navigators

Other Settings

Care

Transitions

Program

High


Management

Lay Navigators


Providers

Longitudinal

Intermittent

Gradual

Active


Frequent Assistance

Full Dependence

High

Moderate

Low


Telemanagement

Home

Other Settings

Home-

based

primary

care

High

Intermittent

Gradual

Active


Frequent Assistance

Full Dependence

High

Moderate

Low Proactive Clinical/Symptom

Management


Lay Navigators


Providers

Telemanagement Longitudinal

Comprehensive

Primary

Care


Planning

High

Intermittent

Gradual

Active


Frequent Assistance

Full Dependence

High

Moderate

Low


Management

Health Coaching & Care Coordination Lay Navigators


Providers

Telemanagement

Home

Other Settings

Episodic

Specialty

Palliative

Care

Moderate

HighActive


Frequent Assistance

Full Dependence

High

Moderate

LowComprehensive Advance Care

Planning


Management



Providers

Longitudinal

Telemanagement

Home

Other Settings

Advanced

Illness

Care

Population Served (General) Solutions Offered (General)

Hosp. Risks

*Patient self-rated health not currently available

Decline

Framework

Discussion


Serious Illness Population


Highlighting Patient Needs in

Population Targeting


Self-rated health

Fair

Poor

Hospitalization Risks

Moderate

High

Decline Trajectory

Intermittent

Gradual

Active

Activities of Daily Living


Frequent Assistance

Full Dependence

Care

Management

Needs

Low

Medium

High

Health Status Coping Status

Coping Capability

(Self efficacy, support system, access, SES, mental health,

cognitive ability)

High

Moderate

Low

Functional Status


Coping Capability

ADLsHealth Status*

General Characterization of Existing Care Models

56

Care

Transitions

Home- based

primary

care

Comprehensive

Primary

Care

Specialty

Palliative

Care

Advanced

Illness

Care

Other programs target:

• Frail elderly:

• Behavioral problems,

mental illness, or

cognitive impairment:

• Low social-economic

status:

Health Status

(Decline Trajectory,

Hospitalization Risks)

Coping

Capability

Coping

Capability

Coping

CapabilityADLs

Intermittent

Gradual

Active

High

Moderate

Low

High


Frequent Assistance

Full Dependence

High

Intermittent

Gradual

Active


Frequent Assistance

Full Dependence

High

Moderate

Low

High

Intermittent

Gradual

Active


Frequent Assistance

Full Dependence

High

Moderate

Low

High

Intermittent

Gradual

Active


Frequent Assistance

Full Dependence

High

Moderate

Low

Moderate

HighActive


Frequent Assistance

Full Dependence

High

Moderate

Low

Population Served (General)

Hosp. Risks


Decline

Patient Identification Approaches

Quantitative (Claim-based) Criteria:

Hospitalization/ Rehospitalization

Risk Score/ Assessment

Demographics

Number/ Type of Chronic Conditions and Comorbidities

Prior Utilization Patterns

Qualitative Criteria:

Health Risk Assessment


Translating Patient Identification

Criteria to Patient Needs







Management


Planning

Resources

Lay Navigators


Providers

Mode of Delivery


Home

Physician office/ clinic

Hospital

PAC/LTC facility

Frequency/ Duration

Episodic

Longitudinal


Common Strategies Across Overlapping Population Needs

61

Health Status* ADLs Coping Capability


Resources Mode of Delivery

Frequency/ Duration

Intermittent

Gradual

Active

High

Moderate

Low


Telemanagement

Home EpisodicHigh


Frequent Assistance

Full Dependence

Lay Navigators

Other Settings

Care

Transitions

Program

High


Management

Lay Navigators


Providers

Longitudinal

Intermittent

Gradual

Active


Frequent Assistance

Full Dependence

High

Moderate

Low


Telemanagement

Home

Other Settings

Home-

based

primary

care

High

Intermittent

Gradual

Active


Frequent Assistance

Full Dependence

High

Moderate

Low Proactive Clinical/Symptom

Management


Lay Navigators


Providers

Telemanagement Longitudinal

Comprehensive

Primary

Care


Planning

High

Intermittent

Gradual

Active


Frequent Assistance

Full Dependence

High

Moderate

Low


Management



Providers

Telemanagement

Home

Other Settings

Episodic

Specialty

Palliative

Care

Moderate

HighActive


Frequent Assistance

Full Dependence

High

Moderate

LowComprehensive Advance Care

Planning


Management



Providers

Longitudinal

Telemanagement

Home

Other Settings

Advanced

Illness

Care

Population Served (General) Solutions Offered (General)

Hosp. Risks


Decline

Matching Services to Patient NeedsCare Management Solutions





Management


Planning

Resources

Lay Navigators


Providers

Mode of Delivery


Home

Physician office/ clinic

Hospital

PAC/LTC facility

Frequency/ Duration

Episodic

Longitudinal

Varying Scope Varying Intensity

Outcomes


Person-centered & Value-basedCare Outcomes


Health

Quality of Life

Maximized Functions

Aging in Place

Support

Patient/ Family

Engagement

Self-efficacy

Care Concordance

Translate to specific metrics

under various value-based

payment program domains:

• Quality

• Care Experience

• Cost

Next Phase of Work


Implementation Considerations


Population

Needs

Care

Management

Solutions

Serious Illness Program

Implementation PathCare

Outcomes

Payment

Model

Internal

Capabilities

Regulatory

Framework

Local

Context

Context ConsiderationsQuestions for organizations seeking to implement or

enhance a serious illness program:

Local Context

What is the availability of providers in your area?

What is the size of the potential population? Is there much variation in the types of conditions?

Will you serve a large/ small geographic area?

In what kind of organization are you operating?

Internal Capabilities

Staff?

Expertise?

Technology?

Any capabilities you plan to develop or outsource?

Regulatory Framework

What are the state and federal regulations that impact the type of program you operate or wish to develop?

Payment Model

How will you pay for this program?

Are services covered by Medicare, Medicaid, or private insurance?

Is there a potential to develop partnerships?


Designing a Serious Illness

Program

Identify population

Identify core care outcomes desired

Match care management solutions population and outcomes

Assess available evidence

Identify context considerations

Develop implementation strategies


Project Next Steps

Grade evidence for various care management

programs

Extrapolatecare

management implementation

strategies

Validate

by reviewing existing

programs

(diverse application of

care management

services)

Propose:

• Care management implementation strategies

• Required capabilities

• Key success factors

Identify:

• Barriers

• Opportunities

• Future development

• Emerging innovations


Final CommentsPlease address additional questions and comments to:

Project Manager Theresa Schmidt (primary contact)

[email protected]

202.810.1310

Project Lead Khue Nguyen

[email protected]




Appendix


Key Terms*


*http://www.pewtrusts.org/~/media/assets/2017/02/recommendations-to-the-administration.pdf

Palliative Care is patient- and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care addresses physical, intellectual, emotional, social, and spiritual needs and facilitates patient autonomy, access to information, and choice. It is provided by a specially-trained interdisciplinary team of doctors, nurses, social workers, chaplains and other specialists who work together to provide patients with an extra layer of support. It is appropriate at any age and at any stage in a serious illness; is not restricted by prognosis; and can be provided along with curative treatment.

Hospice is a coordinated model for quality, compassionate care for people facing a life-limiting illness. In hospice, an inter-disciplinary team of physicians, nurses, social workers, chaplains, hospice aides, and others provide expert medical care, pain management, and emotional and spiritual support expressly tailored to the patient’s needs and preferences, while also supporting the patient’s family. Medicare covers hospice for individuals who have been certified by two physicians as having a prognosis of six months or less if the disease follows its normal course, and who agree to forego more aggressive medical treatments. Some private payers have more flexible eligibility criteria.

Serious Illness is a condition that carries a high risk of mortality (though cure may remain a possibility); has a strong negative impact on one’s quality of life and functioning in life roles, independent of its impact on mortality; and/or is burdensome in symptoms, treatments, or caregiver stress. This may be experienced as physical or psychological symptoms; time and activities dominated by the illness’s treatment; and/or the physical, emotional, and financial stress on caregivers and family. The term “advanced illness” overlaps with serious illness and involves many of the same policy issues.

An Advance Care Plan is any document related to advance care planning: legal documents, medical orders, and notes from conversations between individuals and their health care professionals.

http://www.pewtrusts.org/~/media/assets/2017/02/recommendations-to-the-administration.pdf

Timeline of Project Steps

Jan Feb Mar Apr May Jun


White Papers /

Reports Review

2/1-3/15

Convening Session 1

1/1 – 3/31

Care Model Framework Blue Print

2/1 – 4/30

Care Model Literature Review

2/1 – 4/30

Program Assessments

4/1 – 5/31

Convening Session 2

6/1 – 6/31

Final Framework

Report