Critical Pathways to Improved Care for Serious Illness

1. Critical Pathways to Improving Care for Serious Illness Roundtable Discussion on Care Model Framework March 10, 2017 Petrie-Flom/ C-TAC Project on Advanced Care and Health Policy Funded by the Gordon and Betty Moore Foundation

2. 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

3. 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 Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 3

4. Framework Objectives Understand the range of population needs Identify promising solutions Elevate core care outcomes Analyze implementation considerations Evaluate evidence Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 4 Today’s Session Next Steps

5. 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 Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 5

6. 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 MedStar Washington 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 Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 6 *March 10 Presenters

7. Opportunity: From Innovation to Implementation  Where do you start?  Which care model do you use?  How does your effort relate to others? Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 7

9. Serious Illness Care: an Overview of Existing Frameworks ROBIN L. WHITNEY, PHD, RN

10. White Paper Scan Organizations Terminology Identification Components Providers Outcomes Payment Models CRITICAL PATHWAYS TO IMPROVING CARE FOR SERIOUS ILLNESS 10

11. White Paper Author Organizations Coalition 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 CRITICAL PATHWAYS TO IMPROVING CARE FOR SERIOUS ILLNESS 11

12. CRITICAL PATHWAYS TO IMPROVING CARE FOR SERIOUS ILLNESS 12

13. Terminology CRITICAL PATHWAYS TO IMPROVING CARE FOR SERIOUS ILLNESS 13

14. CRITICAL PATHWAYS TO IMPROVING CARE FOR SERIOUS ILLNESS 14

15. Patient Identification Expert Opinion Quantitative Algorithm Optimal CRITICAL PATHWAYS TO IMPROVING CARE FOR SERIOUS ILLNESS 15

16. Common Triggering Criteria Advanced Cancer Dementia Diagnoses Serious Mental Illness Cognitive Impairment Behavioral Health Assistance with ADLs Caregiver Burden Functional Impairments Poverty Access to Care Social Vulnerability Palliative Care Hospice Prognosis Prior Use and Costs Risk Screening: “Would you be surprised?” Risk CRITICAL PATHWAYS TO IMPROVING CARE FOR SERIOUS ILLNESS 16

17. Program Components Comprehensive Assessment Advance Care Planning Care Coordination Symptom Management Self- Management Support Caregiver Support Spiritual Support Home-Based Care Workforce Training CRITICAL PATHWAYS TO IMPROVING CARE FOR SERIOUS ILLNESS 17

18. 24/7 Technology Enabled Concurrent with Active Treatment CRITICAL PATHWAYS TO IMPROVING CARE FOR SERIOUS ILLNESS 18

19. Care Providers Patients Caregivers Interdisciplinary Teams CRITICAL PATHWAYS TO IMPROVING CARE FOR SERIOUS ILLNESS 19

20. Team Composition Registered Nurses Physicians Pharmacists Lay Health Workers Behavioral Health Chaplains Social Workers Core Palliative Care Skills CRITICAL PATHWAYS TO IMPROVING CARE FOR SERIOUS ILLNESS 20

21. 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 CRITICAL PATHWAYS TO IMPROVING CARE FOR SERIOUS ILLNESS 21

22. Payment Structures Shared Risk/ Shared Savings Value or Population- Based Strategies in FFS Models CRITICAL PATHWAYS TO IMPROVING CARE FOR SERIOUS ILLNESS 22

23. Observations on current efforts to provide quality serious illness care Kathleen Kerr Kathleen.kerr@sbcglobal.net 415-439-9789

24. 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 Critical Pathways to Improving Care for Serious Illness 24

25. 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 Critical Pathways to Improving Care for Serious Illness 25

26. 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 Critical Pathways to Improving Care for Serious Illness 26

27. 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 27 Critical Pathways to Improving Care for Serious Illness

28. 1. Several types of organizations sponsor serious illness programs Health systems Medical groups Health plans Hospice & PC organizations Specialty organizations Partnerships Critical Pathways to Improving Care for Serious Illness 28

29. 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 Critical Pathways to Improving Care for Serious Illness 29

30. 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 Critical Pathways to Improving Care for Serious Illness 30

31. 4. Common to offer a suite of services 31

32. Critical Pathways to Improving Care for Serious Illness 32

33. 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 Critical Pathways to Improving Care for Serious Illness 33

34. 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 appropriateHospice of San Joaquin • Telephonic case management, analytics to identify patients, and "feet on the street" (member engagement)Axispoint Health • Mental health services Beacon Behavioral Health Multi-organization network for a rural, poor county Critical Pathways to Improving Care for Serious Illness 34

35. 5. Safety-net programs have distinct challenges Critical Pathways to Improving Care for Serious Illness 35

36. Palliative care focus areas Patient & Family Symptom Manage- ment Info about Prognosis, Options Assess Values & Translate into Medical Choices Spiritual support Psycho- social support Critical Pathways to Improving Care for Serious Illness 36

37. 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 Critical Pathways to Improving Care for Serious Illness 37

38. 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 Critical Pathways to Improving Care for Serious Illness 38

39. 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/) Critical Pathways to Improving Care for Serious Illness 39

40. 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. Critical Pathways to Improving Care for Serious Illness 40

41. 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 areas 1. Delivery of person-centered, family- oriented EOL care 2. Clinician-patient communication and ACP 3. Professional education and development 4. Policies and payment systems 5. Public education and engagement

42. 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) Critical Pathways to Improving Care for Serious Illness 42

44. Framework Objectives Understand the range of population needs Identify promising solutions Elevate core care outcomes Analyze implementation considerations Evaluate evidence Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 44 Today’s Session Next Steps

45. 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 Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 45

46. Implementation Considerations Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 46 Population Needs Care Management Solutions Serious Illness Program Implementation Path Care Outcomes Payment Model Internal Capabilities Regulatory Framework Local Context

47. 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 Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 47

48. Defining Serious Illness Population Needs Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 48 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

49. Care Management Solutions Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 49 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

50. Care Outcomes Health Quality of Life Maximized Functions Aging in Place Support Patient/ Family Engagement Self-efficacy Care Concordance Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 50

51. Care Manage- ment Needs General Care Model Development Pathways 51 Serious Illness Population Care Management Interventions 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 Care Management Solutions 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- ization Risks Decline Trajectory Self-rated Health Functional Status: Occasional Assistance Frequent Assistance Full Dependence ADLs Coping Status: High Moderate Low Coping Capability © 2017 C-TAC

52. Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC General Characterization of Existing Care Models 52 Health Status* ADLs Coping Capability Care Management Interventions Resources Mode of Delivery Frequency/ Duration Intermittent Gradual Active High Moderate Low Health Coaching & Care Coordination Telemanagement Home EpisodicHigh Occasional Assistance Frequent Assistance Full Dependence Lay Navigators Other Settings Care Transitions Program High Proactive Clinical/Symptom Management Lay Navigators Care Management Clinicians Providers Longitudinal Intermittent Gradual Active Occasional Assistance Frequent Assistance Full Dependence High Moderate Low Health Coaching & Care Coordination Telemanagement Home Other Settings Home- based primary care High Intermittent Gradual Active Occasional Assistance Frequent Assistance Full Dependence High Moderate Low Proactive Clinical/Symptom Management Health Coaching & Care Coordination Lay Navigators Care Management Clinicians Providers Telemanagement Longitudinal Comprehensive Primary Care Comprehensive Advance Care Planning High Intermittent Gradual Active Occasional Assistance Frequent Assistance Full Dependence High Moderate Low Proactive Clinical/Symptom Management Health Coaching & Care Coordination Lay Navigators Care Management Clinicians Providers Telemanagement Home Other Settings Episodic Specialty Palliative Care Moderate High Active Occasional Assistance Frequent Assistance Full Dependence High Moderate Low Comprehensive Advance Care Planning Proactive Clinical/Symptom Management Health Coaching & Care Coordination Lay Navigators Care Management Clinicians 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

55. Highlighting Patient Needs in Population Targeting Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 55 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 Status Coping Capability (Self efficacy, support system, access, SES, mental health, cognitive ability) High Moderate Low Functional Status

56. Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 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 Capability ADLs Intermittent Gradual Active High Moderate Low High Occasional Assistance Frequent Assistance Full Dependence High Intermittent Gradual Active Occasional Assistance Frequent Assistance Full Dependence High Moderate Low High Intermittent Gradual Active Occasional Assistance Frequent Assistance Full Dependence High Moderate Low High Intermittent Gradual Active Occasional Assistance Frequent Assistance Full Dependence High Moderate Low Moderate High Active Occasional Assistance Frequent Assistance Full Dependence High Moderate Low Population Served (General) Hosp. Risks *Patient self-rated health not currently available Decline

57. 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 Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 57

60. Care Management Solutions Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 60 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

61. Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC Common Strategies Across Overlapping Population Needs 61 Health Status* ADLs Coping Capability Care Management Interventions Resources Mode of Delivery Frequency/ Duration Intermittent Gradual Active High Moderate Low Health Coaching & Care Coordination Telemanagement Home EpisodicHigh Occasional Assistance Frequent Assistance Full Dependence Lay Navigators Other Settings Care Transitions Program High Proactive Clinical/Symptom Management Lay Navigators Care Management Clinicians Providers Longitudinal Intermittent Gradual Active Occasional Assistance Frequent Assistance Full Dependence High Moderate Low Health Coaching & Care Coordination Telemanagement Home Other Settings Home- based primary care High Intermittent Gradual Active Occasional Assistance Frequent Assistance Full Dependence High Moderate Low Proactive Clinical/Symptom Management Health Coaching & Care Coordination Lay Navigators Care Management Clinicians Providers Telemanagement Longitudinal Comprehensive Primary Care Comprehensive Advance Care Planning High Intermittent Gradual Active Occasional Assistance Frequent Assistance Full Dependence High Moderate Low Proactive Clinical/Symptom Management Health Coaching & Care Coordination Lay Navigators Care Management Clinicians Providers Telemanagement Home Other Settings Episodic Specialty Palliative Care Moderate High Active Occasional Assistance Frequent Assistance Full Dependence High Moderate Low Comprehensive Advance Care Planning Proactive Clinical/Symptom Management Health Coaching & Care Coordination Lay Navigators Care Management Clinicians 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

62. Matching Services to Patient Needs Care Management Solutions Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 62 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 Varying Scope Varying Intensity

64. Person-centered & Value-based Care Outcomes Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 64 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

66. Implementation Considerations Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 66 Population Needs Care Management Solutions Serious Illness Program Implementation Path Care Outcomes Payment Model Internal Capabilities Regulatory Framework Local Context

67. Context Considerations Questions 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? Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 67

68. 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 Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 68

69. Project Next Steps Grade evidence for various care management programs Extrapolate care 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 Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 69

70. Final Comments Please address additional questions and comments to: Project Manager Theresa Schmidt (primary contact) tschmidt@healthsperien.com 202.810.1310 Project Lead Khue Nguyen khuen@thectac.org Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 70

72. Key Terms* Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 72 *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.

73. Timeline of Project Steps Jan Feb Mar Apr May Jun Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 73 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

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