Scaling Early Palliative Care in Value-Based Community Oncology: A Technology-Enabled Approach

The integration of palliative care alongside oncologic treatment is a best practice strongly recommended by the American Society of Clinical Oncology, a stance reinforced by extensive evidence demonstrating its benefits.¹ Palliative care not only enhances patients’ quality of life through better symptom management but also supports caregivers, mitigates cancer-related distress, reduces aggressive end-of-life care, and may even prolong survival.^2-4 Additionally, it contributes to lower health care costs by decreasing unwanted interventions.^5,6 Acknowledging these advantages, CMS took steps to incentivize integration efforts by launching the Enhancing Oncology Model (EOM) in July 2023. Through the EOM, CMS has tied financial performance-based payments and penalties to 6 quality measures, with 2 directly addressing end-of-life care utilization.⁷ This underscores a significant push within the US health care system to focus on improving end-of-life care as a central mechanism to enhancing quality and bending the cost curve in oncology.

Biqi Zhang, MD

Samyukta Mullangi, MD, MBA

Alphan Kirayoglu, MA

Stephen G. Divers, MD

Julia L. Frydman, MD, MS

Yet despite both professional and governmental calls to action, 3 critical operational challenges have impeded the widespread implementation of palliative care in oncology: (1) correctly “dosing” palliative care in our clinical workflows—surfacing which patients should receive it and at what point in their disease course, (2) ensuring the efficient allocation of palliative care specialists in the face of workforce constraints, and (3) establishing a sustainable economic model that supports palliative care delivery within oncology practices.

Recognizing these barriers, the American Oncology Network (AON), a national alliance of over 275 oncology providers across 20 states, partnered with a value-based cancer care enablement company to develop a scalable palliative care solution in the context of its participation in EOM. Thyme Care (TC), where several of this article’s authors work, brought the technical expertise, data infrastructure, and programmatic support necessary for AON to tackle these challenges. By staffing a novel, multidisciplinary care team available 24/7 that acted as an extension of AON and equipping providers with population-level insights into their patients, this collaboration aimed to redefine how palliative care was integrated into oncology. This article details our approach to overcoming systemic barriers and highlights the strategies that were employed to enhance the value and experience of care for patients facing advanced cancer.

Identifying the Right Patients for Palliative Care: The Serious Illness Registry

The effectiveness of palliative care in oncology depends on its timely delivery to the right patients.^1,8,9 For example, an otherwise fit patient with prostate cancer metastatic to bone whose condition has remained stable on hormone therapy likely does not require immediate palliative care, whereas a patient with nonmetastatic cancer but numerous comorbidities and experiencing high treatment toxicity likely does. However, even with clear criteria for early palliative care engagement, determining who qualifies for engagement in real time remains difficult due to data silos. Painting a complete picture of a patient’s case involves consolidating claims that generally sit with payers; electronic health record (EHR) data that sit with clinicians; admission, discharge, and transfer (ADT) data that sit with clearinghouses; and more. A physician with access to only their own EHR data may not realize that their patient has had repeated hospitalizations—details that can be gleaned from prior authorization and claims feeds—and may benefit from a palliative care team’s focus. To address this, AON and TC codeveloped a triage system that aggregates multiple data streams to more consistently surface individuals meeting serious illness criteria onto a centralized “serious illness registry.”

The purpose of the triage system was to identify, in a data-driven fashion, patients who had uncertain or poor prognoses or high symptom burden. Guided by past studies demonstrating the benefits of early palliative care on certain subsets of patients with cancer, we established the following criteria for inclusion in our serious illness registry: patients with compromised functional status (Eastern Cooperative Oncology Group 3 or 4), stage IV solid tumors (or stage III for lung and pancreatic cancers), or treatment-refractory hematologic malignancies.^10-12 The platform was additionally built to accept not only EHR and claims data but also other inputs, including manually added information, to maximize our ability to detect changes in a patient’s clinical status as close to real time as possible: eg, patients with early-stage tumors with high symptom burden (often surfaced through electronic patient-reported outcomes [ePROs]), high inpatient or emergency department utilization (surfaced through ADT feeds), or nursing judgment (surfaced through direct conversations with each patient). This iterative, adaptive approach was designed so that patients whose clinical status worsened—thereby newly meeting registry criteria—would be promptly surfaced to the care team for intervention.

Overcoming these data silos required contracting with numerous data vendors for ADT feeds, building proprietary ePRO platforms, and leveraging the unique data sharing of claims and prior authorization data by insurers with providers in value-based payment models. Additionally, integrating these data sources—curating, cleaning, normalizing, and surfacing data in a provider-friendly user interface—took the better part of a year and significant financial investment by a motivated practice and value-based care enabler.

Overcoming Workforce Shortages With a Scalable Palliative Care Model

Identifying which patients would benefit from early palliative care was only half the challenge. Even with a robust data model that pinpointed who met registry criteria, we were confronted with the fact that the United States has had a severe shortage of board-certified palliative care clinicians: just 9000 specialists for an estimated 925,000 patients in need.^13,14 AON and TC were tasked with serving 462 patients—28% of AON’s 1652 EOM patients with cancer—who met criteria for early palliative care engagement. Of note, this proportion is concordant with the World Health Organization’s estimates for adults in need of palliative care at the end of life for malignancy (range, 20%-42%, depending on the geographic region), suggesting that our simple model was effectively segmenting the population with cancer into a high-needs subset.¹³

To meet AON’s needs, TC assembled a multidisciplinary serious illness
care team consisting of lay navigators, nurses, nurse practitioners, and palliative care physicians, affording a more scalable model than relying solely on clinical personnel. The team was also licensed to provide care virtually through secure phone or video visits, which relieved the geographic constraints many patients faced.

All registry patients were set to receive “nonspecialist” palliative care, consisting of palliative care education; evaluation of illness and prognosis understanding; basic symptom management; goals, values, and preferences conversations; and documentation of advance directives. Nonclinical community health workers (CHWs) often facilitated these conversations. All team members, both clinical nurses and nonclinical CHWs alike, were trained in core palliative care frameworks, ensuring high-quality, consistent delivery of these services for every patient. Whenever a patient’s needs escalated, they were flagged for “specialist” palliative care as inspired by the STEPPED approach (Temel et al).³ In this model, specialist visits occur at the point of advanced cancer diagnosis and at subsequent decrements in function, rather than on a traditional schedule of fixed appointments.³ Our paradigm similarly emphasized timely, as-needed consultations, ensuring that patients received a baseline of nonspecialized palliative care and then seamlessly transitioned to more intensive support when their clinical needs warranted it.

When specialist palliative care was indicated, TC coordinated referrals with the treating oncologist for approval and alignment. Access to AON’s EHR allowed read-write functionality, enabling 2-way communication without burdening the oncologist’s daily tasks. Specialists then stepped in for advanced symptom management, complex family meetings, and challenging goals-of-care discussions. Whenever possible, TC leveraged practice-affiliated palliative care physicians and, secondarily, specialists in the local market. To expand reach, TC undertook palliative care network mapping in high-density areas to foster local partnerships. If in-person options were not available, TC’s specialists provided virtual palliative care. This layered, flexible approach addressed workforce limitations and administrative challenges, extending palliative care access to all patients who stood to benefit.

Establishing a Sustainable Economic Model for Palliative Care

Although a robust patient registry and a dedicated, multidisciplinary workforce made it feasible to offer palliative care to more patients, the long-term viability of this program hinged on a supportive economic framework. Traditional fee-for-service reimbursement often conflicts with palliative care principles: It is not controversial to point out that in its most successful iteration, palliative care leads to less systemic drug therapy in the overall population and can thereby curtail the revenue streams on which many oncology practices depend.

Under value-based frameworks like the EOM, the focus on reducing care costs while improving care quality naturally aligns with the tenets of palliative care. Meanwhile, TC’s broader partnerships with multiple similar risk-bearing entities created the economic conditions necessary to invest in the personnel and data infrastructure required to ideate, launch, and continuously iterate upon this care model and scale it across contracts. Both AON and TC are set to share in the rewards and potential penalties tied to their performance under EOM, which has fostered a mutual commitment to patient well-being and cost-effective care. Additionally, through its capital funding structure, TC offered reinsurance to offset possible downside risk, ensuring financial stability for AON as it transitioned to value-based care.

Limitations
As with any new intervention, certain limitations remain. As a third-party service, TC’s palliative care team has often had to “borrow the trust” of the primary oncologist to successfully engage patients. Without endorsement from their oncologist, patients are understandably reluctant to engage with a novel third-party. We have codeveloped unified scripting and had AON oncologists introduce the TC service during visits to ease the transition. Another challenge has been streamlining e-prescribing workflows across multiple platforms, which can be cumbersome and time intensive. Finally, although our virtual approach expands access for remote patients—and research has suggested that virtual palliative care is noninferior to in-person care, especially considering that the real-world alternative would be no palliative care—the risk of losing important nuances in physical assessment and bedside rapport remains.¹⁵ To prioritize connecting individuals with local providers whenever possible, we continue expanding our on-the-ground partnerships. We are currently in the early stages of this initiative and await comparative population-level data from CMS as the EOM matures; these performance metrics will help us benchmark our progress and refine the model further. We will also continue refining the model using feedback from patients, their caregivers, and their providers through experience questionnaires.

Conclusion
We present a cohesive palliative care model that sought to address 3 notable barriers to more widespread integration of palliative care into oncology: identifying which patients would benefit from early palliative care, staffing a team that could deliver timely care and scale to meet patients’ needs, and establishing a viable economic model. By building a dynamic serious illness registry that integrates data from multiple sources, we were able to proactively flag patients with advanced cancer who stood to benefit from early palliative care. Next, we assembled a multidisciplinary workforce capable of delivering nonspecialist and specialist services via virtual consultations as well as connecting patients directly with local palliative care providers. Finally, we leveraged the EOM to align financial incentives, making it feasible for a motivated oncology network and an enablement partner to invest in the necessary technology and people up front.

As of the time of this writing, it has been 6 months since the model’s launch. Although it is too soon to measure definitive impacts such as acute care utilization at the end of life and total cost of care, preliminary monitoring indicates promising engagement: Of the 190 members in our serious illness registry who were prioritized for nonspecialty palliative care, 52% (98) have completed conversations with the TC team. In addition, 18% (48 of 272) of those who were triaged for specialty referral have been successfully connected with a local palliative care specialist, seen via our virtual specialist team, or enrolled in hospice. These initial signals suggest that an integrated approach—combining data, technology, and a scalable care model under a value-based framework—has the potential to deliver impactful care for individuals facing advanced cancer. We anticipate gathering more evidence throughout 2025 to critically evaluate the efficacy of this intervention and, hopefully, demonstrate the potential of doubling down on palliative care in
enhancing the value of oncology care.

Author Information
Biqi Zhang, MD, is a general surgery resident at Mass General Brigham in Boston, Massachusetts, and a senior product manager for Thyme Care, with headquarters in Nashville, Tennessee. Samyukta Mullangi, MD, MBA, is a senior medical director for Thyme Care and medical oncologist for Tennessee Oncology, also headquartered in Nashville. Alphan Kirayoglu, MA, is vice president of data science for Thyme Care. Stephen G. Divers, MD, is a board-certified medical oncologist and hematologist for Genesis Cancer and Blood Institute, based in Hot Springs, Arkansas, and chief medical officer for American Oncology Network, with headquarters in Fort Myers, Florida. Julia L. Frydman, MD, MS, is senior medical director for Thyme Care.

For Correspondence
Please direct correspondence to Biqi Zhang, MD, at biqi@thymecare.com.

Financial Support
No sources of support.

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