The National Academy for State Health Policy (NASHP)
TFA Analytics aims to assist state Medicaid agencies in crafting a palliative care services benefit. This assistance will involve furnishing these agencies with essential demographic information and prevailing healthcare usage patterns. The objective is to help them formulate a compelling rationale for advancing the design of this benefit through the appropriate Medicaid governing body. The project will draw upon openly accessible data and data summaries volunteered by Medicaid agencies that are enthusiastic about offering enough data to facilitate state-level analysis. The proposal encompasses an examination of summarized data for five states as part of the project scope.
Palliative Care in Heart Failure (PCHF)
The collaboration between the American Heart Association (AHA) and the Coalition to Transform Advanced Care (C-TAC) led to the launch of the “PCHF Initiative” (Improving Quality of Life for People with Heart Failure through Integration of Palliative Care Services) earlier this year. This initiative sets out to achieve four primary objectives:
- Establish criteria to determine which heart failure patients should be referred to palliative care services.
- Create a standardized process for referring eligible heart failure patients to palliative care.
- Develop educational materials, including outreach resources, to support enrollment in the program.
- Contribute to the growing body of evidence supporting the integration of palliative care services into cardiology care for individuals with heart failure.
A significant focus of this initiative revolves around defining clear eligibility and referral criteria, ensuring timely access to palliative care services for heart failure patients. Moreover, the initiative aims to incorporate up-to-date clinical guidelines and best practices for palliative care seamlessly into current clinical workflows within healthcare systems and plans.
In addition to the involvement of leading clinical experts, representatives from four states— Alabama, California, Hawai’i, and Louisiana—are actively participating in both the planning and implementation phases of this endeavor. The project engages health plans, healthcare systems, and state coalitions, all united in their shared objective of enhancing the quality of life for individuals confronting serious illnesses.
Multi-Payor Learning Collaborative
In collaboration with TFA Analytics, the Coalition to Transform Advanced Care (C-TAC) has embarked on a multi-payor learning collaborative.
C-TAC has dedicated its federal policy efforts to ensuring the effective implementation of interdisciplinary services for individuals with serious illnesses. This commitment extends to creating opportunities for federal agencies to glean insights from the innovations of private payers, thereby improving their own care models and benefits.
Within this framework, our objectives include establishing a neutral platform for payors, be they individuals, organizations, or entities, to exchange best practices and insights. We also provide comprehensive technical support and facilitate engagement with a diverse array of stakeholders, fostering innovation and collaboration. Additionally, we prioritize the accumulation of compelling data to support the funding and expansion of effective, high-quality care models. Our initiative further enables participants to stay informed about and collaborate on innovative projects and initiatives being implemented nationwide. Lastly, we actively seek opportunities for federal advocacy, advocating for policies that enhance the accessibility and quality of care for individuals grappling with serious illnesses.
Similarly, the Goals of Care Coalition New Jersey shares a common objective in its pursuit of improved palliative care for patients with cancer. Their goal is to comprehensively identify the locations, methods, and recipients of palliative care services, with a keen focus on understanding and quantifying the existing gaps in access. The data collected through this endeavor will serve as a vital foundation for advocating increased access to palliative care services and for advocating for workforce training initiatives to meet the needs of the population. These efforts are intended to drive positive changes in state and federal policies, ultimately enhancing the accessibility and quality of palliative care for patients facing cancer and their families.
Community Based Nursing Services (CBNS)
Adventist Health is a provider of myriad medical and clinical services, including community-based nursing services (CBNS) and primary care services to people with or are at high-risk for complex medical conditions in the Tillamook and surrounding regions of Northwest Oregon. Adventist is contracted with insurance companies to deliver primary care services to their members throughout the Tillamook region, including Columbia-Pacific CCO’s Medicaid and Dual Eligible members. In addition to primary care services, Adventist Health delivers nursing services to beneficiaries in the ambulatory and home settings, providing health coaching, care management, health screenings, and other clinical services. Adventist Health is working with Oregon Health and Sciences University (OHSU) to pilot a reimbursement mechanism that will support CBNS delivery to high-risk and complex beneficiaries in the region.
Based on previous experience and published literature on similar models, CBNS has demonstrated favorable outcomes related to improved patient satisfaction, improved care coordination, lower utilization of low value services, and lower total cost of care overall. Sustainable reimbursement to maintain the staff needed to deliver CBNS services and proactive identification of appropriate beneficiaries will maximize value of CBNS in the region. The objective is to establish a financially viable Community-Based Nursing Services (CBNS) program aimed at aiding patients with chronic illnesses in managing their health from the comfort of their homes while minimizing unnecessary and less effective healthcare interventions.
Palliative Care Everywhere – Hawai’i
To achieve health equity and improve the health and well-being of the MQD population, a formal Palliative Care Services Benefit needs to be developed and available to QUEST Integration (QI) members across settings. This would ensure that there is a minimum standard and clear guidance for the delivery of these services, including through managed care organizations (MCOs), that could already be offering some or all of these services via Medicare and/or commercial plan products. It is projected that by implementing a formalized Palliative Care Services Benefit, MQD would be able to mitigate the unsustainable costs for this population.
MQD seeks to address gaps in care for seriously ill QI members by ensuring that access to a Palliative Care Services Benefit is available throughout the continuum of care and across care settings. This benefit would encompass the provision of a range of coordinated, specialized palliative care services delivered by an interprofessional team skilled in delivering person-centered care outside of the hospital and hospice settings and be made available to seriously ill beneficiaries across geographies and cultural settings. By administering palliative care as a coordinated benefit, MQD seeks to ensure that beneficiaries with serious illness receive synergistic, coordinated care that focuses on anticipating and preventing pain and symptoms rather than just addressing and treating needs after they arise. Further, by improving care experience through this coordinated benefit, MQD expects to be able to reduce costly, low-value care not in line with member treatment preferences resulting in budget neutrality for the delivery palliative care services for both Medicaid only and dual eligible beneficiaries.
A serious illness is “[a] health condition that carries a high risk of mortality and either negatively impacts a person’s daily function or quality of life or excessively strains the caregiver.”1 This definition has been widely adopted, including by the National Committee for Quality Assurance (NCQA) and the National Quality Forum (NQF).
QI members of all ages face the challenge of living with serious illnesses, such as advanced cancer, heart disease, Alzheimer’s disease, and other chronic conditions. It has been well documented1 that approximately 34% of total healthcare costs stem from 5% of the population. Evaluation of current healthcare costs for QI members follow this trajectory, with approximately 5% of members incurring 45% of overall healthcare costs. Those 5% of members have multiple chronic conditions or the diagnosis of a serious health condition, receiving unmanaged and uncoordinated care that results in multiple readmissions and facility stays. This fragmented care impacts the overall care experience for the member as well as care quality. In addition, significant disparities exist for this population, resulting in limited access to high-quality services and poor health outcomes for people with serious illness across cultures and geography.
People with serious illness who speak languages other than English and those living on Hawai‘i’s less populated islands are less likely to be asked about care preferences than their White counterparts, are less likely to have their pain adequately managed, and are less likely to have access to care in a home setting. By ensuring that all QI members have equal access to palliative care services delivered in a coordinated manner by an interdisciplinary team and covered through a value-based payment model, MQD stands to improve quality of life and care quality for some of our most vulnerable members and prevent and address the leading drivers of healthcare costs for people with serious illness. A coordinated care and payment model to deliver high quality palliative care services can reduce utilization of unwanted medical treatments and identify and address social risk factors and other social determinants of health. Health plans will require providers to follow assessment requirements for those with specialized health needs that include screening questions for social risk factors to ensure that care and services addressing social determinants can be coordinated alongside the delivery of palliative care services for an individual’s serious illness (described in more detail in a subsequent section).