March 10, 2017 Learn more on our website: http://petrieflom.law.harvard.edu/events/details/critical-pathways-to-improved-care-for-serious-illness.

1. Critical Pathways to Improving Care for
Serious Illness
Roundtable Discussion on Care Model Framework
March 10, 2017
Petrie-Flom/ C-TAC Project on Advanced Care and Health Policy
Funded by the Gordon and Betty Moore Foundation

2. Petrie-Flom / C-TAC Project on
Advanced Care and Health Policy
 Collaboration between C-TAC and the Petrie-Flom Center for
Health Law Policy, Biotechnology, and Bioethics at Harvard Law
School
 Launched in 2016 to “foster development of improved models of
care for individuals with serious advanced illness nearing end-of-
life, and to apply interdisciplinary analysis to important health law
and policy issues raised by adoption of new person-centered
approaches to care for this growing population”
 C-TAC thanks Petrie-Flom and project partners:
 Healthsperien
 The Betty Irene Moore School of Nursing at UC Davis
 The Center to Advance Palliative Care (CAPC)
 Kathleen Kerr
 Gordon & Betty Moore Foundation
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 2

3. Project Objectives
 Develop a flexible serious illness care model implementation
framework within a 6-months timeframe
 Framework establishes the context for how consideration of evidence
fits into the design of a serious illness program
 Framework should identify common program elements but recognize
the need for local variation in program design and implementation
related to factors like payment model, internal capabilities, care
setting, etc.
 Framework purpose:
 Inform serious illness program development, replication, and scaling
 Integrate with care model payment design
 Inform care model Proforma simulator development
 Inform other aspects of design and development such as policy,
standardized measurements, and regulatory analysis
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 3

4. Framework Objectives
Understand the range of
population needs
Identify promising solutions
Elevate core care outcomes
Analyze implementation
considerations
Evaluate evidence
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 4
Today’s
Session
Next
Steps

5. Agenda
 10:30-10:50am, Introduction and Overview
 10:55-11:00am, Why Develop an Implementation Framework?
 11:00-11:30am, Discussion of Current Programs and White Papers
 11:30-11:50am, Serious Illness Care Model Framework Objectives
 11:50am-12:00, Audience Q&A
 12:00-12:30pm, Lunch/Networking
 12:30-2:00pm, Discussion of Serious Illness Care Model
 Overarching Model
 Population
 Solutions
 Goals
 Next Phase of Work: Implementation Roadmap Design
 2:00-2:30pm, Conclusion and Q&A
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 5

6. Convening Session Panelists
 Panelists
 Namita Ahuja MD, Sr. Medical Director, Medicare, UPMC
Health Plan; Clinical Assistant Professor of Medicine,
University of Pittsburgh
 K. Eric De Jonge MD, Director of Geriatrics at MedStar
Washington Hospital Center; Associate Professor of
Medicine, Georgetown University School of Medicine
 Timothy Ferris MD, MPH, Senior Vice President of
Population Health Management, Partners HealthCare and
Mass General Hospital
 Muriel Gillick MD, Director, Program in Aging, Harvard
Pilgrim Health Care Institute and Professor of Population
Medicine, Harvard Medical School
 Anna Gosline SM, Senior Director of Health Policy and
Strategic Initiatives, Blue Cross Blue Shield of
Massachusetts
 Lauran Hardin MSN, RN-BC, CNL, Senior Director Cross
Continuum Transformation, National Center for Complex
Health and Social Needs, Camden Coalition of Healthcare
Providers
 Emma Hoo, Director, Pacific Business Group on Health
 Sally Okun RN, MMHS, Vice President, Advocacy, Policy,
and Patient Safety, PatientsLikeMe
 Russell Portenoy MD, Chief Medical Officer, MJHS
Hospice and Palliative Care; Executive Director, MJHS
Institute for Innovation in Palliative Care; Professor of
Neurology and Family and Social Medicine, Albert Einstein
College of Medicine
 Monique Reese DNP, ARNP, FNP-C, ACHPN, Chief
Clinical Officer, Sutter Care at Home
 Jennifer Valenzuela MSW, MPH, Principal of Program
Department, HealthLeads
 Project Partners
 Robin Whitney PhD, Assistant Professor, University of
California San Francisco School of Medicine*
 Kathleen Kerr, Healthcare Consultant, Kerr Healthcare
Analytics*
 Allison Silvers MBA, Vice President, Payment and Policy,
Center to Advance Palliative Care (CAPC)*
 Janice Bell PhD, MPH, MN, Associate Professor at the
Betty Irene Moore School of Nursing, University of
California, Davis
 C-TAC and Healthsperien
 Tom Koutsoumpas, Co-Founder and Co-Chair, Coalition
to Transform Advanced Care (C-TAC)*
 Khue Nguyen PharmD, Chief Operating Officer, C-TAC
Innovations*
 Gary Bacher JD, MPA, Founding Member of
Healthsperien, Co-Director, Smarter Healthcare Coalition*
 Mark Sterling JD, MPP, Senior Fellow, Project on
Advanced Care and Health Policy, Petrie-Flom Center at
Harvard Law School; Chief Strategy Officer, C-TAC
Innovations*
 Jon Broyles MS, Executive Director, C-TAC
 Theresa Schmidt MA, PMP, Vice President of Strategy,
Healthsperien; Director of Data and Quality, National
Partnership for Hospice Innovation
 Brad Stuart MD, Chief Medical Officer, C-TAC
 David Longnecker MD, Chief Clinical Innovations Officer,
C-TAC
 Nick Martin Director, Communications & Outreach, C-TAC
 Sibel Ozcelik ML, MS, Research and Implementation
Coordinator, C-TAC
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 6
*March 10 Presenters

7. Opportunity:
From Innovation to Implementation
 Where do you start?
 Which care model do you use?
 How does your effort relate to others?
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 7

8. Serious Illness Landscape
White Papers & Care Models
UC Davis School of Nursing, Kathleen Kerr, CAPC
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 8

9. Serious Illness Care:
an Overview of
Existing Frameworks
ROBIN L. WHITNEY, PHD, RN

10. White Paper Scan
Organizations Terminology Identification Components
Providers Outcomes
Payment
Models
CRITICAL PATHWAYS TO IMPROVING CARE FOR SERIOUS
ILLNESS
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11. White Paper Author
Organizations
Coalition to Transform Advanced Care
(C-TAC)
Health Care Transformation Task Force
(HCTTF)
Center to Advance Palliative Care (CAPC)
Common Practice
Institute for Healthcare Improvement
(IHI)
The Conversation Project (TCP)
RAND Health
American Hospital Association (AHA)
National Academy of Social Insurance
National Consensus Project for Palliative
Care
SeniorBridge
Agency for Healthcare Quality and
Research (AHRQ)
Mathematica
Robert Wood Johnson Foundation
(RWJF)
Center for Health Care Strategies
Health Industry Forum
National Academy of Medicine
CRITICAL PATHWAYS TO IMPROVING CARE FOR SERIOUS
ILLNESS
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12. CRITICAL PATHWAYS TO IMPROVING CARE FOR SERIOUS
ILLNESS
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13. Terminology
CRITICAL PATHWAYS TO IMPROVING CARE FOR SERIOUS
ILLNESS
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14. CRITICAL PATHWAYS TO IMPROVING CARE FOR SERIOUS
ILLNESS
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15. Patient Identification
Expert
Opinion
Quantitative
Algorithm
Optimal
CRITICAL PATHWAYS TO IMPROVING CARE FOR SERIOUS
ILLNESS
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16. Common Triggering Criteria
Advanced Cancer
Dementia
Diagnoses
Serious Mental Illness
Cognitive Impairment
Behavioral Health
Assistance with ADLs
Caregiver Burden
Functional Impairments
Poverty
Access to Care
Social Vulnerability
Palliative Care
Hospice
Prognosis
Prior Use and Costs
Risk Screening: “Would you be surprised?”
Risk
CRITICAL PATHWAYS TO IMPROVING CARE FOR SERIOUS
ILLNESS
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17. Program Components
Comprehensive
Assessment
Advance Care
Planning
Care
Coordination
Symptom
Management
Self-
Management
Support
Caregiver
Support
Spiritual
Support
Home-Based
Care
Workforce
Training
CRITICAL PATHWAYS TO IMPROVING CARE FOR SERIOUS
ILLNESS
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18. 24/7
Technology
Enabled
Concurrent
with Active
Treatment
CRITICAL PATHWAYS TO IMPROVING CARE FOR SERIOUS
ILLNESS
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19. Care Providers
Patients Caregivers
Interdisciplinary
Teams
CRITICAL PATHWAYS TO IMPROVING CARE FOR SERIOUS
ILLNESS
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20. Team Composition
Registered
Nurses
Physicians
Pharmacists
Lay Health
Workers
Behavioral
Health
Chaplains
Social
Workers
Core Palliative Care Skills
CRITICAL PATHWAYS TO IMPROVING CARE FOR SERIOUS
ILLNESS
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21. Outcomes
Utilization
• ED visits
• Inpatient Admissions
• ICU stays
Costs
• Total Spending
• Cost-benefit analysis
Process Measures
• Documentation of ACP
discussion
• Completion of pain
assessment
Patient Reported
Outcomes
• QOL
• Satisfaction with care
CRITICAL PATHWAYS TO IMPROVING CARE FOR SERIOUS
ILLNESS
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22. Payment Structures
Shared Risk/
Shared Savings
Value or
Population-
Based
Strategies in
FFS Models
CRITICAL PATHWAYS TO IMPROVING CARE FOR SERIOUS
ILLNESS
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23. Observations on current efforts
to provide quality
serious illness care
Kathleen Kerr
Kathleen.kerr@sbcglobal.net
415-439-9789

24. Objective
Observations culled from…
• Multiple CHCF initiatives related to community-based PC
– Payer-provider partnerships
– Expanding access to PC in safety net systems
– Expanding access to PC in rural areas
– SB1004 implementation support
• GBM assignment
– Identification of 100 serious illness programs
– 14 case profiles
• Mr. B
Share observations about the current state of serious
illness care, to inform improvement efforts
Critical Pathways to Improving Care for
Serious Illness
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25. Patient population for GBM work
• Poor prognosis and are likely in the last stage
of life (which could last for years)
• Experience functional impairment
• At risk for cycling in and out of the hospital in
absence of additional supports
Critical Pathways to Improving Care for
Serious Illness
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26. Essential (ideal) elements of serious illness programs
Team-based
approach
Goal-based
approach
Concordant
care
Comprehensive
care
Coordinated
services
Transition
supports
Home-based
care
Rapid access to
services
Family-oriented
care
Caregiver
support
Measurement
Critical Pathways to Improving Care for
Serious Illness
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27. Core (observed) serious illness program services
(in addition to concurrent access to disease-directed care)
1. Pain and symptom management
2. Medication management and reconciliation
3. Medical information / prognostication support
4. Goals of care & advance care planning discussions, and assistance with
documentation
5. Case management / care coordination
6. Transition support
7. Psycho-emotional support for patients
8. Emotional support for family caregivers
9. Spiritual care
10. Referrals to community resources for assistance with social and practical
needs (or provide such services directly)
11. 24 / 7 service or strategies to ensure expanded access
12. Bereavement support or referrals
27
Critical Pathways to Improving Care for
Serious Illness

28. 1. Several types of organizations sponsor serious
illness programs
Health
systems
Medical
groups
Health plans
Hospice & PC
organizations
Specialty
organizations
Partnerships
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Serious Illness
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29. 2. Core services offered via a wide range of
interventions
Home-based
primary care
Specialty geriatric
services
Specialty
palliative care
Specialty care
units
Care
management
services
Navigation /
coaching
programs
Transition
management
programs
Structured ACP
programs
Social supports
and services
Spiritual care
programs
Support programs
for families /
caregivers
Complementary
and integrative
medicine services
Hospice
Critical Pathways to Improving Care for
Serious Illness
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30. 3. Variation abounds (which might be OK)
• Eligible/target patients
• Strategies for identifying patient population
• Scope of service
• Care settings
• When engage, frequency of contact, length of service
• Staffing (which disciplines) and staffing ratios
• Training requirements
• Use of lay staff and volunteers
• Degree of integration with primary / specialty services
(referring providers)
• Metrics
• Payment models and payment amount
• Number of customers
Critical Pathways to Improving Care for
Serious Illness
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31. 4. Common to offer a suite of services
31

32. Critical Pathways to Improving Care for
Serious Illness
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33. System-based programs cross settings
and service lines
AllinaHealth Abbott Northwestern Hospital – Minneapolis
Full array of primary and specialty services, home health and case
management plus …
• specialty palliative care available in multiple settings
• embedded specialty geriatric care in transitional care units, nursing
homes and assisted living communities
• medical home for individuals with complex conditions
• advance care planning classes offered at multiple clinics
• lay navigator program (LifeCourse)
• hospice care
Variation across markets, campuses within markets, and
accessibility depending on disease, age, insurance
Critical Pathways to Improving Care for
Serious Illness
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34. Multi-organization efforts are common
• Funding, plus support from Clinical Analytics, Case
Managers, Social Workers, pt transportation costsHPSJ
• Primary and specialty care, plus inpatient and clinic-based
palliative care
San Joaquin General
Hospital
• Home-based palliative care, with ability to transition to
hospice as appropriate
Community Palliative &
Hospice Care
• Home-based palliative care, with ability to transition to
hospice as appropriateHospice of San Joaquin
• Telephonic case management, analytics to identify patients,
and "feet on the street" (member engagement)Axispoint Health
• Mental health services
Beacon Behavioral
Health
Multi-organization network for a rural, poor county
Critical Pathways to Improving Care for
Serious Illness
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35. 5. Safety-net programs have distinct challenges
Critical Pathways to Improving Care for
Serious Illness
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36. Palliative care focus areas
Patient
& Family
Symptom
Manage-
ment
Info about
Prognosis,
Options
Assess
Values &
Translate
into Medical
Choices
Spiritual
support
Psycho-
social
support
Critical Pathways to Improving Care for
Serious Illness
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37. Patient
& Family
Symptom
Manage-
ment
Info about
Prognosis,
Options
Assess
Values &
Translate
into Medical
Choices
Spiritual
support
Mental Health Care
Companionship
Caregiver issues
Access to food
Transportation
Housing & Physical safety
Legal support
Financial support
Safety-net palliative care focus areas
Critical Pathways to Improving Care for
Serious Illness
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38. 6. Rural programs have distinct challenges
• Distance / geography
• Less than optimal voice / data connectivity
• Opioid epidemic / other substance abuse
• Poverty
• Older, isolated population
• Few available providers
#1
#2
#3
Total travel time between visit 1-2
and visit 2-3 = 4 minutes
Implications for ….
• Clinical model / scope
• Staffing-training /
partnerships
• Caseload
• Cost of care, potential impact
Critical Pathways to Improving Care for
Serious Illness
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39. 7. Multiple funding options … but not universally available
• Support from parent organization (quality/operational
value, loss leader, mission)
• Traditional FFS billings
• Hospice benefit
• Health plan contracts (multiple business lines)
• Serve MA/ MA SNP / Medicaid Managed Care population
• Serve ACO population (Medicare and commercial)
• Serve global/full capitation population (PACE)
• CMS demonstrations/Innovation programs: IAH, Oncology
Care Model / ESRD Care Model, CCTP, MCCM, CPC+
Terrific reference: CAPC’s Payment Primer: What to know about payment for
palliative care delivery (https://www.capc.org/topics/payment/)
Critical Pathways to Improving Care for
Serious Illness
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40. 8. Funding doesn’t solve all problems
• Workforce
– “It has been difficult to achieve rapid scale of our model
and ramp up services to cover a larger geography.
Workforce shortages and competition in the market for
talented palliative care providers continues to be a
challenge.”
• Rescue and repair
– “About 90% of patients referred to Transitions do not know
that their diseases are terminal.”
• Willing referring providers
– “Let’s see what the cath results are and if there is nothing
more we can do then I’ll refer to palliative care”
• Willing patients
– Must be … open to more support, open to strangers in the
home, able to get to clinic, can afford co-pays, etc.
Critical Pathways to Improving Care for
Serious Illness
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41. Dying in America: Improving Quality and Honoring
Individual Preferences Near the End of Life
IOM (Institute of Medicine). 2014. Dying in America: Improving quality
and honoring individual preferences near the end of life. Washington,
DC: The National Academies Press.
Turns out they were on to something …
Five improvement /focus areas
1. Delivery of person-centered, family-
oriented EOL care
2. Clinician-patient communication and
ACP
3. Professional education and
development
4. Policies and payment systems
5. Public education and engagement

42. Food for thought
1. Many types of providers / sponsors … consider getting input from all
2. Range of patient and family needs/preferences requires a suite of
interventions … not just one thing, and often not just one
organization
3. There are particular challenges when delivering care in the safety-
net and to rural populations; these may impact staffing and training,
care model, program costs, expected impact, and more
4. Some success with existing funding options, but program scope and
design often limited by what gets paid for
5. Consider focus on integration / coordination / education as
solutions to workforce issues, and to promote buy-in from patients
and providers
6. While there are many challenges, there are also are many promising
programs and practices operating currently (it’s probably okay to be
a little optimistic)
Critical Pathways to Improving Care for
Serious Illness
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43. Serious Illness
Care Model
Framework
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 43
C-TAC and Healthsperien

44. Framework Objectives
Understand the range of
population needs
Identify promising solutions
Elevate core care outcomes
Analyze implementation
considerations
Evaluate evidence
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 44
Today’s
Session
Next
Steps

45. Framework Design Considerations
 Design to support implementation decision-making
 See the universe through modular building blocks
 Global view consists of “generic” high-level descriptors,
span across care models/patient care programs
 Detailed view conveys range of operational
applications
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 45

46. Implementation Considerations
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 46
Population
Needs
Care
Management
Solutions
Serious Illness Program
Implementation Path
Care
Outcomes
Payment
Model
Internal
Capabilities
Regulatory
Framework
Local
Context

47. Designing a Serious Illness
Program
Identify
population
Identify core
care outcomes
desired
Match care
management
solutions
population and
outcomes
Assess
available
evidence
Identify context
considerations
Develop
implementation
strategies
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 47

48. Defining Serious Illness
Population Needs
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 48
Self-rated
health
Fair
Poor
Hospitalization
Risks
Moderate
High
Decline
Trajectory
Intermittent
Gradual
Active
Activities of
Daily Living
Occasional
Assistance
Frequent
Assistance
Full
Dependence
Care
Management
Needs
Low
Medium
High
Health Status
Coping
Capability
(Self efficacy,
support system,
access, SES,
mental health,
cognitive ability)
High
Moderate
Low
Coping StatusFunctional Status

49. Care Management Solutions
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 49
Care
Management
Interventions
Health Coaching and
Care Coordination
Proactive
Clinical/Symptom
Management
Comprehensive
Advance Care
Planning
Resources
Lay Navigators
Care Management
Clinicians
Providers
Mode of
Delivery
Virtual (phone, video,
sensors/ monitors)
Home
Physician office /
clinic
Hospital
PAC/LTC facility
Frequency/
Duration
Episodic
Longitudinal

50. Care Outcomes
Health
Quality of Life
Maximized
Functions
Aging in Place
Support
Patient/ Family
Engagement
Self-efficacy
Care
Concordance
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 50

51. Care
Manage-
ment
Needs
General Care Model
Development Pathways
51
Serious Illness Population
Care
Management
Interventions
Health
Coaching and
Care
Coordination
Proactive
Clinical/Symp
tom
Management
Comprehe-
nsive
Advance Care
Planning
Resources
Lay
Navigators
Care
Management
Clinicians
Providers
Mode of
Delivery
Tele-
management
Home
Physician
office / clinic
Hospital
PAC/LTC
facility
Frequency/
Duration
Episodic
Longitudinal
Care Management Solutions
Correlation
between
Parameters
Decline Trajectory
Functional /
Coping Status
Service Intensity
& Scope
Team Resources
& Home Support
Health Status:
Fair
Poor
Moderate
High
Intermittent
Gradual
Active
Hospital-
ization
Risks
Decline
Trajectory
Self-rated
Health
Functional
Status:
Occasional
Assistance
Frequent
Assistance
Full
Dependence
ADLs
Coping
Status:
High
Moderate
Low
Coping
Capability
© 2017 C-TAC

52. Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC
General Characterization of Existing Care Models
52
Health Status* ADLs Coping
Capability
Care
Management
Interventions
Resources Mode of
Delivery
Frequency/
Duration
Intermittent
Gradual
Active
High
Moderate
Low
Health Coaching &
Care Coordination
Telemanagement
Home EpisodicHigh
Occasional
Assistance
Frequent
Assistance
Full Dependence
Lay Navigators
Other Settings
Care
Transitions
Program
High
Proactive
Clinical/Symptom
Management
Lay Navigators
Care Management
Clinicians
Providers
Longitudinal
Intermittent
Gradual
Active
Occasional
Assistance
Frequent
Assistance
Full Dependence
High
Moderate
Low
Health Coaching &
Care Coordination
Telemanagement
Home
Other Settings
Home-
based
primary
care
High
Intermittent
Gradual
Active
Occasional
Assistance
Frequent
Assistance
Full Dependence
High
Moderate
Low Proactive
Clinical/Symptom
Management
Health Coaching &
Care Coordination
Lay Navigators
Care Management
Clinicians
Providers
Telemanagement Longitudinal
Comprehensive
Primary
Care
Comprehensive
Advance Care
Planning
High
Intermittent
Gradual
Active
Occasional
Assistance
Frequent
Assistance
Full Dependence
High
Moderate
Low
Proactive
Clinical/Symptom
Management
Health Coaching &
Care Coordination Lay Navigators
Care Management
Clinicians
Providers
Telemanagement
Home
Other Settings
Episodic
Specialty
Palliative
Care
Moderate
High
Active
Occasional
Assistance
Frequent
Assistance
Full Dependence
High
Moderate
Low
Comprehensive
Advance Care
Planning
Proactive
Clinical/Symptom
Management
Health Coaching &
Care Coordination Lay Navigators
Care Management
Clinicians
Providers
Longitudinal
Telemanagement
Home
Other Settings
Advanced
Illness
Care
Population Served (General) Solutions Offered (General)
Hosp.
Risks
*Patient self-rated health not currently available
Decline

53. Framework
Discussion
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 53

54. Serious Illness Population
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 54

55. Highlighting Patient Needs in
Population Targeting
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 55
Self-rated
health
Fair
Poor
Hospitalization
Risks
Moderate
High
Decline
Trajectory
Intermittent
Gradual
Active
Activities of
Daily Living
Occasional
Assistance
Frequent
Assistance
Full
Dependence
Care
Management
Needs
Low
Medium
High
Health Status Coping Status
Coping
Capability
(Self efficacy,
support system,
access, SES,
mental health,
cognitive ability)
High
Moderate
Low
Functional Status

56. Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC
Coping
Capability
ADLsHealth Status*
General Characterization of Existing Care Models
56
Care
Transitions
Home- based
primary
care
Comprehensive
Primary
Care
Specialty
Palliative
Care
Advanced
Illness
Care
Other programs target:
• Frail elderly:
• Behavioral problems,
mental illness, or
cognitive impairment:
• Low social-economic
status:
Health Status
(Decline Trajectory,
Hospitalization Risks)
Coping
Capability
Coping
Capability
Coping
Capability
ADLs
Intermittent
Gradual
Active
High
Moderate
Low
High
Occasional
Assistance
Frequent
Assistance
Full Dependence
High
Intermittent
Gradual
Active
Occasional
Assistance
Frequent
Assistance
Full Dependence
High
Moderate
Low
High
Intermittent
Gradual
Active
Occasional
Assistance
Frequent
Assistance
Full Dependence
High
Moderate
Low
High
Intermittent
Gradual
Active
Occasional
Assistance
Frequent
Assistance
Full Dependence
High
Moderate
Low
Moderate
High
Active
Occasional
Assistance
Frequent
Assistance
Full Dependence
High
Moderate
Low
Population Served (General)
Hosp.
Risks
*Patient self-rated health not currently available
Decline

57. Patient Identification Approaches
 Quantitative (Claim-based) Criteria:
 Hospitalization/ Rehospitalization
 Risk Score/ Assessment
 Demographics
 Number/ Type of Chronic Conditions and Comorbidities
 Prior Utilization Patterns
 Qualitative Criteria:
 Health Risk Assessment
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 57

58. Translating Patient Identification
Criteria to Patient Needs
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 58

59. Care Management Solutions
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 59

60. Care Management Solutions
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 60
Care
Management
Interventions
Health Coaching and
Care Coordination
Proactive
Clinical/Symptom
Management
Comprehensive
Advance Care
Planning
Resources
Lay Navigators
Care Management
Clinicians
Providers
Mode of
Delivery
Virtual (phone, video,
sensors/ monitors)
Home
Physician office/
clinic
Hospital
PAC/LTC facility
Frequency/
Duration
Episodic
Longitudinal

61. Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC
Common Strategies Across Overlapping Population Needs
61
Health Status* ADLs Coping
Capability
Care
Management
Interventions
Resources Mode of
Delivery
Frequency/
Duration
Intermittent
Gradual
Active
High
Moderate
Low
Health Coaching &
Care Coordination
Telemanagement
Home EpisodicHigh
Occasional
Assistance
Frequent
Assistance
Full Dependence
Lay Navigators
Other Settings
Care
Transitions
Program
High
Proactive
Clinical/Symptom
Management
Lay Navigators
Care Management
Clinicians
Providers
Longitudinal
Intermittent
Gradual
Active
Occasional
Assistance
Frequent
Assistance
Full Dependence
High
Moderate
Low
Health Coaching &
Care Coordination
Telemanagement
Home
Other Settings
Home-
based
primary
care
High
Intermittent
Gradual
Active
Occasional
Assistance
Frequent
Assistance
Full Dependence
High
Moderate
Low Proactive
Clinical/Symptom
Management
Health Coaching &
Care Coordination
Lay Navigators
Care Management
Clinicians
Providers
Telemanagement Longitudinal
Comprehensive
Primary
Care
Comprehensive
Advance Care
Planning
High
Intermittent
Gradual
Active
Occasional
Assistance
Frequent
Assistance
Full Dependence
High
Moderate
Low
Proactive
Clinical/Symptom
Management
Health Coaching &
Care Coordination Lay Navigators
Care Management
Clinicians
Providers
Telemanagement
Home
Other Settings
Episodic
Specialty
Palliative
Care
Moderate
High
Active
Occasional
Assistance
Frequent
Assistance
Full Dependence
High
Moderate
Low
Comprehensive
Advance Care
Planning
Proactive
Clinical/Symptom
Management
Health Coaching &
Care Coordination Lay Navigators
Care Management
Clinicians
Providers
Longitudinal
Telemanagement
Home
Other Settings
Advanced
Illness
Care
Population Served (General) Solutions Offered (General)
Hosp.
Risks
*Patient self-rated health not currently available
Decline

62. Matching Services to Patient Needs
Care Management Solutions
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 62
Care
Management
Interventions
Health Coaching and
Care Coordination
Proactive
Clinical/Symptom
Management
Comprehensive
Advance Care
Planning
Resources
Lay Navigators
Care Management
Clinicians
Providers
Mode of
Delivery
Virtual (phone, video,
sensors/ monitors)
Home
Physician office/
clinic
Hospital
PAC/LTC facility
Frequency/
Duration
Episodic
Longitudinal
Varying Scope Varying Intensity

63. Outcomes
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 63

64. Person-centered & Value-based
Care Outcomes
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 64
Health
Quality of Life
Maximized
Functions
Aging in Place
Support
Patient/
Family
Engagement
Self-efficacy
Care
Concordance
Translate to specific metrics
under various value-based
payment program domains:
• Quality
• Care Experience
• Cost

65. Next Phase of Work
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 65

66. Implementation Considerations
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 66
Population
Needs
Care
Management
Solutions
Serious Illness Program
Implementation Path
Care
Outcomes
Payment
Model
Internal
Capabilities
Regulatory
Framework
Local
Context

67. Context Considerations
Questions for organizations seeking to implement or
enhance a serious illness program:
 Local Context
 What is the availability of providers in your area?
 What is the size of the potential population? Is there much variation in the types of
conditions?
 Will you serve a large/ small geographic area?
 In what kind of organization are you operating?
 Internal Capabilities
 Staff?
 Expertise?
 Technology?
 Any capabilities you plan to develop or outsource?
 Regulatory Framework
 What are the state and federal regulations that impact the type of program you operate
or wish to develop?
 Payment Model
 How will you pay for this program?
 Are services covered by Medicare, Medicaid, or private insurance?
 Is there a potential to develop partnerships?
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 67

68. Designing a Serious Illness
Program
Identify
population
Identify core
care outcomes
desired
Match care
management
solutions
population and
outcomes
Assess
available
evidence
Identify context
considerations
Develop
implementation
strategies
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 68

69. Project Next Steps
Grade evidence
for various care
management
programs
Extrapolate
care
management
implementation
strategies
Validate
by reviewing
existing
programs
(diverse
application of
care
management
services)
Propose:
• Care
management
implementation
strategies
• Required
capabilities
• Key success
factors
Identify:
• Barriers
• Opportunities
• Future
development
• Emerging
innovations
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 69

70. Final Comments
Please address additional questions and comments to:
Project Manager Theresa Schmidt (primary contact)
tschmidt@healthsperien.com
202.810.1310
Project Lead Khue Nguyen
khuen@thectac.org
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 70

71. Appendix
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 71

72. Key Terms*
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 72
*http://www.pewtrusts.org/~/media/assets/2017/02/recommendations-to-the-administration.pdf
Palliative Care is patient- and family-centered care
that optimizes quality of life by anticipating,
preventing, and treating suffering. Palliative care
addresses physical, intellectual, emotional, social,
and spiritual needs and facilitates patient autonomy,
access to information, and choice. It is provided by a
specially-trained interdisciplinary team of doctors,
nurses, social workers, chaplains and other
specialists who work together to provide patients with
an extra layer of support. It is appropriate at any age
and at any stage in a serious illness; is not restricted
by prognosis; and can be provided along with
curative treatment.
Hospice is a coordinated model for quality,
compassionate care for people facing a life-limiting
illness. In hospice, an inter-disciplinary team of
physicians, nurses, social workers, chaplains,
hospice aides, and others provide expert medical
care, pain management, and emotional and spiritual
support expressly tailored to the patient’s needs and
preferences, while also supporting the patient’s
family. Medicare covers hospice for individuals who
have been certified by two physicians as having a
prognosis of six months or less if the disease follows
its normal course, and who agree to forego more
aggressive medical treatments. Some private payers
have more flexible eligibility criteria.
Serious Illness is a condition that carries a high risk
of mortality (though cure may remain a possibility);
has a strong negative impact on one’s quality of life
and functioning in life roles, independent of its impact
on mortality; and/or is burdensome in symptoms,
treatments, or caregiver stress. This may be
experienced as physical or psychological symptoms;
time and activities dominated by the illness’s
treatment; and/or the physical, emotional, and
financial stress on caregivers and family. The term
“advanced illness” overlaps with serious illness and
involves many of the same policy issues.
An Advance Care Plan is any document related to
advance care planning: legal documents, medical
orders, and notes from conversations between
individuals and their health care professionals.

73. Timeline of Project Steps
Jan Feb Mar Apr May Jun
Critical Pathways to Improving Care for Serious Illness, © 2017 C-TAC 73
White Papers /
Reports Review
2/1-3/15
Convening Session 1
1/1 – 3/31
Care Model Framework Blue Print
2/1 – 4/30
Care Model Literature Review
2/1 – 4/30
Program Assessments
4/1 – 5/31
Convening Session 2
6/1 – 6/31
Final Framework
Report