Introduction: Studies show that home-based palliative care (HBPC) improves participant outcomes and satisfaction with care while also decreasing hospitalizations and emergency department visits. U.S. health care payment reforms create financial opportunities to offer HBPC. Consequently, more HBPC programs are emerging, heightening the need to evaluate their effectiveness. Methods: This randomized, controlled trial is comparing the effectiveness of an evidence-based model of HBPC and enhanced usual primary care for participants who receive primary care from medical groups and clinics organized under an accountable care organization or Medicare Advantage plan. Palliative care services are reimbursed by our partnering health plan provider. The five-year trial will enroll 1155 seriously ill participants (and *884 of their caregivers) with heart failure, chronic obstructive pulmonary disease, or advanced cancer. We are collecting data via telephone surveys with participants at baseline and one and two months postenrollment and with caregivers at baseline, one and two months postenrollments, and following the death of a loved one. We are collecting participant-reported outcome measures of pain, symptoms, anxiety, depression, participant-provider communication, and hope. Caregiver outcome measures include caregiver burden, communication with providers, anxiety, and depression. Additional outcomes are participant survival time and participants' emergency department visits and hospitalizations. Study Implementation: Challenges and Contributions: Our research team has encountered several significant challenges in early study implementation. These include engaging primary care providers in the study and coordinating logistics with a health plan. Both challenges have contributed to a lag in participant enrollment. Despite these challenges, our study holds tremendous promise to accelerate adoption and spread of an evidencebased HBPC model across the country.
Objective: To examine frontline providers' experiences implementing home-based palliative care (HBPC) covered by a private health insurer in partnership with community-based hospice, home health, and Accountable Care Organizations.Study setting: Primary data collection at three community-based hospice and home health organizations in Northern and Southern California at the outset of the new private payer-contracted HBPC.Study design: Qualitative focus groups with frontline HBPC providers.Data collection: Focus groups were guided by a nine-item, semi-structured research protocol, audio-recorded, transcribed verbatim, and analyzed by two independent coders using a grounded theory approach.Principal findings: Participants (n = 24) were mostly White (79.2%) female (91.7%) aged 39 years or less (62.5%), and from diverse disciplines. Three major themes were identified: (1) patient referrals, (2) organizational factors, and (3) HBPC reimbursement. Findings highlight barriers and facilitators to implementing HBPC covered by an insurer including the organization's community reputation, the dynamic/ "teaminess" of the HBPC team, having a site champion/"quarterback," and issues from a siloed medical system. Participants also discussed challenges with patient referrals, specifically, lack of palliative care knowledge (both providers and patients/ families) and poor communication with patients referred to HBPC.Conclusions: This study found that despite a favorable perception of payercontracted HBPC by frontline providers, barriers and facilitators persist, with patient accrual/referral paramount.community-based organizations, frontline clinicians, health insurance, home healthcare, homebased palliative care, hospice, person-centered care, qualitative methods What is known on this topic• Home-based palliative care (HBPC) is an important way to deliver person-centered care for patients and caregivers affected by serious illnesses.• However, without a reimbursement stream, implementation and sustainment of HBPC programs outside of closed health systems have been stymied.The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Torrie Fields was employed by Blue Shield of California at the time this study was conducted and for a portion of manuscript development.
Background: Before the Affordable Care Act (ACA), the financing landscape for fee-for-service health care lacked broad structure and incentives to provide palliative care outside hospitals. Since the ACA, several payers have taken the opportunity to offer home-based palliative care (HBPC) to their members. Objective: To evaluate the impact of outreach efforts by a physician champion among a cohort of primary care physicians (PCPs) to introduce a new HBPC program and benefit, obtain buy-in, and motivate referrals for Blue Shield patients. Design: Secondary qualitative analysis of detailed field notes from a HBPC physician champion from in-person meetings with a cohort of PCPs and their office staff. Subjects: PCPs were from a physicians group in northern California that met with the physician champion during a 12-month study period. Results: During the 12-month study period, the physician champion met with clinicians at 27 distinct primary care offices. Qualitative analyses revealed three independent themes relating to receptivity and perception of the new HBPC program: (1) physician-level factors (overburdened, lack of palliative care knowledge, misconceptions around palliative care, and patient control), (2) practice-level factors (practice structure and role/integration of advance practice providers), and (3) first impression of the HBPC program (receptivity, ''dirty data,'' and communication). Conclusion: Results hold important implications for practice and new approaches to engaging PCPs in HBPC, obtaining buy-in, and generating patient referrals. PCPs need better support in caring for patients with serious illness and HBPC can likely fill that role if PCPs are willing to refer and HBPC programs adapt.
Describe the needs of DT-LVAD patients beyond their medical therapy and identify measures that support the multidisciplinary LVAD team. Destination therapy left ventricular assist devices (DT-LVAD) offer life in the setting of ultimate death with the device in situda trajectory that can be complicated for patients, caregivers, and providers. Advancements in LVAD technology and the growing concept of a truly multidisciplinary team have set the stage for a comprehensive program of support. However, with this life-sustaining therapy challenges persist in our endeavors to improve clinical and non-clinical outcomes. Significant challenges may arise for DT-LVAD patients, caregivers, and teams as patients transition from chronic LVAD support to comfort oriented care, in which a device may be properly functioning but the body weakening or a device decompensating in an otherwise stable patient. Although caregivers endure substantial burdens throughout the LVAD support trajectory, the level of caregiver burnout fluctuates and requires monitoring. Our focus in caring for this population must be twofolddon extending quality of life with this distinctive technology while simultaneously acknowledging the processes that will ultimately lead to end-of-life. Early and ongoing engagement of palliative care teams and DT-LVAD specific advance care planning (ACP) has the potential to augment patient-centered care and hone quality of life based interventions for patients and families. In this concurrent session, clinicians from a multidisciplinary team will define a novel approach to understanding the DT-LVAD advanced illness trajectory, reveal engaging strategies to break through barriers of complex ACP, uncover how bi-directional communication and education can enhance multidisciplinary team function, highlight the needs of DT-LVAD patients and caregivers beyond medical therapies, and discuss expanding options for approaching end-of-life care. Data from quality improvement work will provide an understanding of patient and caregiver quality of life approaching endof-life, clinician reported challenges, and system improvements in ACP processes. This session will offer clear strategies for redefining institutional best practices in collaborative and comprehensive DT-LVAD care.
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