Seamless Life Care to the End of Life
The home health care industry continues to make good progress in providing seamless care for the growing number of frail elderly Americans living with multiple chronic illnesses. We have been steadily moving away from fee-for-service and embracing integrated services and holistic oversight across the spectrum of need to keep people safe and healthy as they age at home.
All too often, however, the seamlessness of care falls away when people need it most: at or near the end of life, with hospice and palliative care typically “carved out” of managed care. The services are covered, but for people to benefit they have to enroll in a separate hospice or palliative care program — with all the attendant “red tape” and fragmentation of care that can cause. It can be very difficult for people to understand or take advantage of the care options that are available to support them and their families in the last stages of life.
There has to be a better way. In fact, nine forward-looking U.S. health care organizations are piloting that better way right now. I’m thrilled that the organization I lead, VNSNY CHOICE Health Plans, is participating in the demonstration program, the Medicare Advantage Value-Based Insurance Design (VBID) model, which began in January 2021 and is expected to run until December 2024. At the heart of the model is a hospice and palliative care “carve-in,” which means those benefits are included in the plan. When individuals are identified as likely to benefit from hospice or palliative care, we can begin to plan for the next stages of life with them and connect them and their families with the information, resources and team members they need to seamlessly receive that additional layer of support. They don’t need to disenroll or enroll in anything new or different, and — importantly — their care teams work closely together to ensure individuals and families experience the best quality of life possible all the way through the end of life.
“Our goal is to make sure that people are getting the right care at the right time in the right setting,” says my colleague Josie Aquino, who is managing our demonstration plan. “We care for people for years. We’re experts at handling really difficult, complicated chronic cases, and we’re also able to make a graceful segue into the next stages of life as painlessly as possible for families.”
While the details of our demonstration program might seem technical, the day-to-day impact they can have on people’s lives is profound. Take a typical plan member, an 82-year-old man with diabetes, hypertension and congestive heart failure who has managed his symptoms at home for years with the help of his care team. He has grown increasingly short of breath and faces serious vision and circulatory problems from diabetes. Thanks to the plan’s carve-in, he could now be identified as benefiting from additional palliative or end-of-life services and could be directly connected to them. (The identification might come from the plan member’s dedicated care manager, who oversees all aspects of care and may foresee a deteriorating health trajectory, or from VNSNY’s systems that flags people who could qualify for and benefit from palliative or end-of-life care.)
The care team could then begin conversations with the member and his family about their goals at this stage of the illness, including advance care planning and advance directives, and, depending on his prognosis, could connect them with palliative or hospice care. The care manager — who knows the member well — would communicate regularly with the palliative or hospice interdisciplinary care teams, with the goal of ensuring that he receives the appropriate level of care at all times.
Palliative Care: an Important Step in the Journey
Palliative care plays an important role in this seamless care journey. Indeed, all programs participating in the demonstration are required to have a palliative care program (which we do as part of the Visiting Nurse Service of New York’s Care Management Organization). “Often, people aren’t aware of their options, what’s out there to help them,” says June Stanley, who heads the palliative care program. “We have the expertise to educate and listen to each person.” Recently, June sat down with a plan member’s son and explained how palliative care could help his father breathe easier as his COPD worsened. “We’ll manage his oxygen so he’s not becoming short of breath,” she told the son. “We’ll look at his medications, we’ll visit more often and call to see how he’s doing. We’ll put him on some monitoring, and all the services will be coordinated.”
Says Carolyn Sage, who oversees VNSNY nurse practitioners delivering palliative care, “We reach people at the point where we’re seeing those chronic conditions starting to decline, but they’re not quite ready for hospice. Maybe they’re losing weight, having trouble breathing, struggling with a nonhealing wound. They do need that extra level of care and support to help them understand the chronicity of their illness and get them ready for what’s to come down the road.” It takes time, understanding and patience.
People often confuse hospice and palliative care, because both provide specialized care at the latter stages of an illness. Hospice refers to a complete array of end-of-life care — including nurse-led symptom management, spiritual care, social work, bereavement services — for people whose prognosis suggests they are in their final six months of life. Palliative care provides specialized medical care for people whose conditions have grown precipitously more serious but who may not be in their final six months and who may want to continue curative treatment. Often, people progress from palliative care into hospice when the time is right.
The Benefits of Seamlessness
Fragmented care too often results in duplication of or missing services, overpayments, and underutilization of hospice and short lengths of stay. “When the right hand doesn’t know what the left is doing, the member feels that disconnection, which they certainly shouldn’t be feeling during the end of life, when they have so much going on,” says Josie.
Through this novel model of care many years in the making, we hope to increase appropriate and timely access to end-of-life and palliative care and better coordinate services with each plan member’s existing care team. The numbers from the demonstration program are still small in its first year, but already we are seeing people benefiting from palliative care’s additional level of services and access to comprehensive hospice care earlier in their diagnosis — which means they and their families enjoy benefits longer and have more time to focus on living life to its fullest when it becomes clear that time is short.
