What Are the Models for Delivering Palliative Care in the Home?

Introduction and Scope of the Problem

By 2030, an estimated 73.1 million people in the United States, 21% of the population, will be over the age of 65. By 2034, older adults will outnumber children for the first time in U.S. history. As the population ages, the number of people living with multiple chronic conditions and serious illness continues to rise and places a growing burden on the U.S. health system. Many of these individuals suffer cognitive or functional impairment and have difficulty or need assistance in leaving the home. In 2011, an estimated two million individuals were homebound, and this figure is expected to grow substantially as the baby boomer generation ages. These individuals have complex medical needs and a high symptom burden compounded by poverty, isolation, and limited health literacy. In addition, while short-term mortality rates in this population are high (20% 1-year mortality), many have unpredictable prognoses or may not wish to forgo curative treatment, rendering them ineligible for hospice care; for this population, home-based palliative care offers great benefit. While both hospital- and clinic-based palliative care services have grown substantially in the last decade, the growth of home-based services has lagged. The gap in access to home-based palliative care (HBPalC) represents an opportunity to enhance the quality of care for community-dwelling adults with serious illness, improve care transitions, and avoid hospitalizations where these are unwarranted or unnecessary. HBPalC, as part of a comprehensive package of services to support community-dwelling people with serious illness, multimorbidity, and cognitive or functional impairment, is central to ensuring the health of the growing population of adults with serious illness in the United States.

Summary of Models and Evidence Supporting Their Benefits

Models of Palliative Care in the Home

Until recently, HBPalC programs were operated by a small group of progressive health systems and community agencies. There has been a rapid expansion in the number of HBPalC programs in the United States in recent years, fueled by evidence from studies demonstrating the beneficial impact on outcomes for patients (discussed shortly) and the potential to generate savings within value-based care arrangements. All models center on an interdisciplinary team, trained in the principles and practice of palliative care. The recent community-based palliative care certification program for home care, available through The Joint Commission, specifies that a physician, a registered nurse or advanced practice nurse, a social worker, and a chaplain or spiritual care provider should serve as the core interdisciplinary team. For the interdisciplinary team, seeing patients in their own home affords a unique perspective on the patient’s life and a fuller picture of the patient as a whole person, a principle that is essential to palliative care. It allows the clinical team to assess a patient’s symptom burden and functional status in the context of their own environment, to meet separately with family members and caregivers to assess their needs and provide support, and to rapidly assess other social determinants of health. Finally, the home can provide a familiar and comfortable environment within which to engage in challenging conversations. While the interdisciplinary team is a constant in models of home-based palliative care, there are many differences between programs, discussed shortly, which influence the delivery of care.

Origins of Home-Based Palliative Care and Revenue Streams

HBPalC programs in the United States have emerged from five organizational homes: home health agencies, hospice agencies, hospital-based or health system–based programs that have expanded into the community, and multistate providers. Additionally, while HBPalC can be provided within a home-based primary care (HBPC) program through a team-based practice model, not all HBPC programs will have this focus or the requisite training. These different programs generate revenue in different ways, with implications for the population served and care delivered. Programs run out of a home health agency are most likely funded through a regular home health benefit and are thus required to follow the associated rules and regulations. These programs identify eligible patients on enrollment to ensure that they can be managed by the specific home health team that has training in palliative care. Within these programs, it is important to have providers with the capacity to go to the home to assess and provide care and suggest care plans to the primary care physician overseeing the episode of care. In addition, 24-hour on-call nursing support is of critical importance in driving beneficial outcomes. HBPalC programs that are part of a hospice agency can act effectively to support patients’ transition from HBPalC to hospice and may be sustained in part through revenue generated from increased enrollment in hospice. Often these are also funded through a home health benefit or through specific health plans. Programs established by hospitals or the health systems target patients with high needs and acute care utilization; these programs can bill for the professional services (e.g., physician, advanced practice provider), and additional costs are often funded by the health system as part of a broader strategy to improve quality of care and generate savings supported by value-based arrangements. In recent years, programs have been established by independent multistate providers; these companies contract with health insurances (e.g., on a per-member per-month basis) to provide services to identified patients as a plan benefit. Finally, programs that deliver home-based primary and palliative care that need additional revenue beyond their professional billing to sustain their programs can do so through shared savings/risk arrangements such as those within accountable care organizations (ACOs).

Staffing for Home-Based Palliative Care

While all HBPalC is interdisciplinary, the precise staffing mix and ratios can vary according to the population served and the financial sustainability of a model in any one market. Many programs are billing provider led (physician, nurse practitioner, and physician assistant) with additional interdisciplinary team members (registered nurse, social worker) supporting delivery of a comprehensive care plan. The advantage of this model is the capacity to generate revenue through providers billing for visits. Rarely does this fee-for-service payment cover the costs of the entire team. Therefore either a health plan or a health system must cover the rest of the team costs. Other programs are composed almost entirely of nonbilling staff (nurses, social workers, community health workers, chaplains) with physician or nurse practitioner support including office-based triaging and care plan development. While these programs may not be financially viable in markets dominated by fee-for-service insurance payments, they do offer the advantage of being deliverable within the context of a shortage of palliative care physicians and advanced practitioners and are thus readily scalable.

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