Bridging the Gap in Advanced Illness

Michael Paletta, MD FAAHPM

Many of us practicing hospice and palliative medicine have long struggled with the gap between persons coping with advancing illness and persons failing despite aggressive management. Patients seem to cross from the first group to the second quickly, almost without notice. Late referral to hospice is a natural result of this difficulty in identifying patients who are properly managed and compliant, yet whose disease is progressing, and whose final months often feature crisis care in emergency and intensive care settings. Palliative care offers interdisciplinary management, but trained providers are few, and services in many areas remain tied to hospitals and medical centers.

We at Hospice of Michigan, through our innovation division − The Maggie Allesee Center, sought to identify persons with serious illness earlier in their decline trajectory, before the suffering and the cost of multiple hospitalizations devastates their final months. Using Medicare claims data and a proprietary predictive model, we developed an integrative program, At Home SUPPORT ™, blending EMR access, telephone support, after hours visits, and family/caregiver training. The caregiver emphasis has been particularly effective for, after all, it is they who call 911 in a lonely panic, or encourage hospital admission as respite for their own exhaustion. Our partnerships with Accountable Care Organizations focus on the 5% of patients who generate 50% of costs and have yielded data supporting diminished ED use, fewer hospitalizations, increased and earlier referral to hospice, and diminished caregiver burden. As we expand our partnership database, we plan to further refine this model to a replicable program of advanced illness management.

Has your institution considered ways to reach patients and families earlier in the trajectory of serious illness? What can we learn from one another as we travel this road?

Dr. Paletta serves as Vice President of Medical Affairs for Hospice of Michigan. This post previews the latest installment of AAHPM’s Hospice and Palliative Medicine Profiles in Innovation.