Currently Viewing:
Evidence-Based Oncology April 2015
Palliative Care Integrates Value in Cancer Care
Joseph Alvarnas, MD
NCCN 2015: Reviewing the Past to Build the Future
Joseph Alvarnas, MD
A Need for More, Better, and Earlier Conversations With Cancer Patients About Goals of Care
Rachelle Bernacki, MD, MS; and Ziad Obermeyer, MD, MPhil
Creating Value-Based Metrics for Cancer Care: A Stakeholder-Informed, Evidence-Driven Approach
Scott D. Ramsey, MD, PhD; and Gary H. Lyman, MD, MPH
Q&A on Palliative Care
Andrew Smith
The Challenges With Ensuring the Validity and Utility of Diagnostic Tests
Surabhi Dangi-Garimella, PhD
Study Suggests Lung Cancer Screening Criteria May Not Capture All Smokers Who Need It
Mary K. Caffrey
From Choosing Wisely, Advice for Palliative Care Specialists and Guidance for Cancer Patients
Mary K. Caffrey
When Is the Right Time for Palliative Care in Oncology? The Sooner, the Better!
Marian Grant, DNP, CRNP, ACHPN, FPCN
How and Why Oncologists Should Do Palliative Care-or Get Some Assistance Doing It
Alessandra Colaianni, BA, MPhil; Sarina Isenberg, BA, MA; and Thomas J. Smith, MD, FACP, FASCO, FAAHPM
Palliative and End-of-Life Care: Issues, Challenges, and Possible Solutions in the United States
Kashyap Patel, MD; and Mary Kruczynski
Global Outlook on Palliative Care in Cancer
Megan O’Brien, PhD
Comprehensive Support for Individuals Living With Prostate Cancer and Their Caregivers Complements Palliative Care Services
Dan Klein, and Jamie Bearse
Patient, Physician, and Payer Conversations in Palliative Care: Moving Beyond Fear
Patti Forest, MD, MBA, FAAFP
Trading Conflict for Synergy: The New Normal for Oncology and Palliative Care
Michael D. Fratkin, MD
Currently Reading
The Role of Palliative Care in Accountable Care Organizations
Amy S. Kelley, MD, MSHS; and Diane E. Meier, MD

The Role of Palliative Care in Accountable Care Organizations

Amy S. Kelley, MD, MSHS; and Diane E. Meier, MD

Sharp HealthCare in San Diego, California, has developed the Transitions Advanced Illness Management program in conjunction with their afliated Pioneer ACO.30-32 Additional payer relationships with this program include Medicare Advantage and other private managed care contracts, but not Medicare fee-for-service. The cornerstone of the program, which aims to provide individualized, home-based palliative care for patients with serious illness—including those with progressive functional and nutritional decline—is a goals of care discussion with a skilled facilitator, followed by the development of a personalized care plan. Key features of the Transitions services include in-home patient and family education, medication reconciliation, counseling on what to expect and what to do if a crisis arises, caregiver assessment and support, completion of advance care planning and documentation (eg, Physician Orders for Life Sustaining Treatment forms), and expert symptom management.

Sharp notes that the average enrollment for patients on the Transitions program is 5 months, and 75% of enrollees have ultimately transitioned to hospice with an average hospice length of stay far exceeding the national average: 120 days, compared with 72 days. In addition, the program has signicantly reduced acute care utilization, including a 57% reduction in ED visits, 54% reduction in hospital admissions, and 43% reduction in total costs of care.30


To strengthen value, ACOs are working to improve the quality of care and in so doing reduce reliance on avoidable emergency and acute care services for the highest risk, highest cost patient population. Palliative care, an essential partner in this work, has consistently demonstrated its ability to maximize healthcare value, specifically for seriously ill patients with the greatest need and highest risk. Successful programs that have integrated palliative care within an ACO share the following key practices:

• They rigorously target the high-risk population and proactively offer palliative care services.

• They engage in highly skilled discussions of patient goals and personalize care plans to match.

• They assess family and social resources and explicitly address these needs.

• They provide expert symptom management and coordinated medical care across settings.

• They offer maximum flexibility with round-the-clock phone support and service intensity scaled to meet patients’ needs as they change over time.

Providers seeking to develop a palliative care program within an ACO or other innovative payment model may find additional resources and support at EBO


1. About palliative care. Center to Advance Palliative Care website. palliative-care/. Accessed March 3, 2015.

2. The long-term outlook for health care spend- ing. Congressional Budget Office website. MainText3.1.shtml. Published November 13, 2007. Accessed July 25, 2014.

3. National health expenditure data. CMS website. Updated May 5, 2014. Accessed July 25, 2014.

4. The Lewin Group. Individuals living in the community with chronic conditions and functional limitations: a closer look. HHS website. http:// pdf. Published January 2010. Accessed March 9, 2015.

5. Aldridge MD, Kelley AS. Epidemiology of serious illness and high utilization of healthcare. In: Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life: Committee on Approaching Death: Addressing Key End of Life Issues. Washington, DC: National Academies Press; 2014.

6. Hanson LC, Danis M, Garrett J. What is wrong with end-of-life care? Opinions of bereaved family members. J Am Geriatr Soc. 1997;45(11):1339- 1344.

7. Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: Blueprint for Transform- ing prevention, Care, Education, and Research. Washington, DC: National Academies Press; 2011.

8. Teno JM, Clarridge BR, Casey V, et al. Family perspectives on end-of-life care at the last place of care. JAMA. 2004;291(11):88-93.

9. Mitchell SL, Teno JM, Kiely DK, et al. The clini- cal course of advanced dementia. N Engl J Med. 2009;361(16):1529-1538.

10. Higginson IJ, Finlay I, Goodwin DM, et al. Do hospital-based palliative teams improve care for patients or families at the end of life? J Pain Symptom Manage. 2002;23(2):96-106.

11. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742.

12. Bakitas M, Lyons K, Hegel M, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA. 2009;302(7):741-749.

13. Jordhoy MS, Fayers P, Loge JH, Ahlner- Elmqvist M, Kaasa S. Quality of life in palliative cancer care: results from a cluster randomized trial. J Clin Oncol. 2001;19(18):3884-3894.

14. Steinhauser KE, Clipp EC, McNeilly M, Christakis NA, McIntyre LM, Tulsky JA. In search of a good death: observations of pa- tients, families, and providers. Ann Intern Med. 2000;132(10):825-832.

15. Balboni TA, Vanderwerker LC, Block SD, et al. Religiousness and spiritual support among advanced cancer patients and associations with end-of-life treatment preferences and quality of life. J Clin Oncol. 2007;25(5):555-560.

16. Higginson IJ, Bausewein C, Reilly CC, et al. An integrated palliative and respiratory care service for patients with advanced disease and refractory breathlessness: a randomised controlled trial. Lancet Respir Med. 2014;2(12):979-987.

17. Kane RL, Klein SJ, Bernstein L, Rothenberg R, Wales J. Hospice role in alleviating the emotional stress of terminal patients and their families. Med Care. 1985;23(3):189-197.

18. Wright AA, Zhang B, Ray A, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA. 2008;300(14):1665-1673.

19. Wright AA, Keating NL, Balboni TA, Matulonis UA, Block SD, Prigerson HG. Place of death: correlations with quality of life of patients with cancer and predictors of bereaved caregivers’ mental health. J Clin Oncol. 2010;28(29):4457-4464.

20. Abernethy AP, Currow DC, Fazekas BS, Luszcz MA, Wheeler JL, Kuchibhatla M. Specialized palliative care services are associated with improved short- and long-term caregiver outcomes. Supportive Care Cancer. 2008;16(6):585-597.

21. Gelfman LP, Meier DE, Morrison RS. Does palliative care improve quality? a survey of bereaved family members. J Pain Symptom Manage. 2008;36(1):22-28.

22. Morrison RS, Penrod JD, Cassel JB, et al. Cost savings associated with US hospital palliative care consultation programs. Archives Inter Med. 2008;168(16):1783-1790.

23. Smith S, Brick A, O’Hara S, Normand C. Evidence on the cost and cost-effectiveness of palliative care: a literature review. Palliat Med. 2014;28(2):130-150.

24. Rabow M, Kvale E, Barbour L, et al. Moving upstream: a review of the evidence of the impact of outpatient palliative care. J Palliat Med. 2013;16(12):1540-1549.

25. Brumley R, Enguidanos S, Jamison P, et al. Increased satisfaction with care and lower costs: results of a randomized trial of in-home palliative care. J Am Geriatr Soc. 2007;55(7):993-1000.

26. Rabow MW, Dibble SL, Pantilat SZ, McPhee SJ. The comprehensive care team: a controlled trial of outpatient palliative medicine consultation. Arch Intern Med. 2004;164(1):83-91.

27. National Palliative Care Registry Annual Survey Summary. Center to Advance Palliative Care website. portals/1/Reports/Registry_Summary%20Re- port_2014.pdf. Published July 2014. Accessed March 2, 2014.

28. Hong CS, Siegel AL, Ferris TG. Caring for high-need, high-cost patients: what makes for a successful care management program? Issue Brief (Commonw Fund). 2014;19:1-19.

29. Fried TR, Tinetti ME, Iannone L, O’Leary JR, Towle V, Van Ness PH. Health outcome prioritization as a tool for decision making among older persons with multiple chronic conditions. Arch Intern Med. 2011;171(20):1854-1856.

30. Hoefer DR, Johnson SK, Bender M. Development and preliminary evaluation of an innovation advanced chronic disease care model. J Clin Outcomes Manage. 2013;20(9):408-418.

31. Transitions Advanced Illness Management Program. Sharp website. .com/hospice/transitions-advanced-illness-management-program.cfm. Accessed March 9, 2015.

32. Johnson SK, Kruse J. Transitions: a program that’s challenging the traditional healthcare mind- set. National Hospice and Palliative Care website. lic/newsline/2010/Sept_10_NL.pdf. Published September 2010. Accessed March 12, 2015.
Copyright AJMC 2006-2020 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
Welcome the the new and improved, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up