Home-Based Palliative Program Is Sentara’s Answer to Post-Acute Care Gaps

While palliative care is often considered a hospital-based extension of hospice, one health system is using it to fill the gaps in its home-based service offerings.

Sentara Healthcare is partnering with Turn-Key Health to make it happen. The new advanced illness services program uses predictive analytics to identify and enroll patients with a higher risk of experiencing avoidable hospitalizations, readmissions or inappropriate death.

The goal of the home-based program is to improve outcomes and reduce costs for eligible patients by bringing in palliative care sooner and more appropriately — and at times, even working concurrently with home health care.

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“This program really allows us to begin palliative care in the home for patients or members with advanced illness, while they continue — if they wish — to seek aggressive treatment,” Linda Huffer, president of Sentara Enterprises, told Home Health Care News. “It’s an added benefit … [to] provide them services of nurses and social workers to help them identify [and achieve] their goals of care.”

Sentara is a health system with $6 billion in total operating revenue, with 11 hospitals in Virginia and one in North Carolina. Its home health arm — which falls under the Sentara Enterprises division — spans most of that geography.

Generally, about 17% of Sentara’s discharges go to its internal home health line. In 2018, about 40,000 patients in total received Sentara’s home health services.

Meanwhile, Philadelphia-based Turn-Key is an affiliate of Enclara Healthcare that provides palliative illness management for health plans and other health care providers.

“It’s a very complementary, patient-centric approach,” Turn-Key President Greer Myers told HHCN. “It’s part of the care continuum that hasn’t really been available until now.”

After patients are identified and enrolled in the program, a social worker or nurse meets with them in-home to develop a care plan.

“Our model is very non-medically oriented in the sense that when our network is in the home, we’re not treating that patient medically,” Myers said. “We’re identifying medical gaps in care and needs. We’re not looking to replace the care they would receive.”

In fact, the program often has synergies with other services, such as home health and home care.

“[If] the member would benefit from having home health or DME or … or if they’re experiencing social isolation and they don’t have caregiver support [or] a way to consistently get meals, we’ll be arranging for meal delivery,” Myers said. “We’ll be arranging for social integration and all of the things that may be untouched by their programs.”

Specifically, the advanced illness program is available through Setara’s partnership with Optima Health Plan, which has about 450,000 members. Turn-Key uses Optima claims data to determine which members are high risk and should be invited to participate in the added benefit.

“The health plans are paying for service because, really, what it’s doing is tackling one of their biggest quality problems and their biggest cost issues,” Myers said. “They don’t have a good way to solve for that problem.”

Before now, Sentara only offered hospital-based palliative care.

“There’s really a gap between palliative care in the hospital versus those that get discharged with really no further care plan,” Sabine Brent, director of referral services for Sentara Home Care, told HHCN. “It’s really to bridge the gap [and] follow those patients into the community and should they need further care … then we can make that transition.”

While Sentara just launched the program this month, Turn-Key has helped facilitate many similar programs over the years with impressive results.

“[The program] essentially ends in a rational reduction of acute-care utilization — fewer hospital stays, fewer ICU stays, lower lengths of stay, fewer ER visits,” Myers said. “Unplanned care and non-beneficial treatment are eliminated by getting ahead of this process from a palliative care perspective and supportive care.”

A similar program by Turn-Key reduced total medical costs for participating members but 20%, ICU admissions by 33% and hospital stays by 12%, according to results published in the Journal of Palliative Medicine.

“The goal is to improve the quality of life for members/patients and their caregivers,” Myers said. “All we have to do is focus on quality improvement and the dollars are there.”

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