Cost Reduction and Utilization Patterns in a Medicare Accountable Care Organization Using Home-Based Palliative Care Services.

Accountable care organizations (ACOs) are often tasked with helping providers to deliver care efficiently and with higher quality outcomes. For an ACO to succeed in delivering efficient care, it is important to direct resources toward patients who exhibit the greatest levels of opportunity while focusing attention toward mitigating their needs. Home-based palliative care (HBPC) services are known to address patient needs for those with serious illness while decreasing the total cost of care (TCC). In this retrospective review, ACO researchers reviewed cost, quality, and utilization patterns for 3418 beneficiaries within a Medicare Shared Saving Program approaching the end of life comparing decedents who received HBPC versus those who did not receive the service. Those individuals who received HBPC services were significantly less likely to be hospitalized (51% reduction in the HBPC group), more likely to use hospice (70% vs. 43%; P = 0.001), and their TCC was less than that of those who did not receive the service ($27,203 vs. $36,089: P = 0.0163). Although more research needs to be done to understand the specific components of care delivery that are helpful in decreasing unnecessary utilization, in this retrospective review in an accountable care population, HBPC is associated with a significant decrease in cost and utilization in a population approaching end of life.

Improving the use of hospice services in nursing homes: a randomized controlled trial.

CONTEXT: Hospice care may improve the quality of end-of-life care for nursing home residents, but hospice is underutilized by this population, at least in part because physicians are not aware of their patients' preferences. OBJECTIVE: To determine whether it is possible to increase hospice utilization and improve the quality of end-of-life care by identifying residents whose goals and preferences are consistent with hospice care. DESIGN, SETTING, AND PARTICIPANTS: Randomized controlled trial (December 2003-December 2004) of nursing home residents and their surrogate decision makers (N=205) in 3 US nursing homes. INTERVENTION: A structured interview identified residents whose goals for care, treatment preferences, and palliative care needs made them appropriate for hospice care. These residents' physicians were notified and asked to authorize a hospice informational visit. MAIN OUTCOME MEASURES: The primary outcome measures were (1) hospice enrollment within 30 days of the intervention and (2) families' ratings of the quality of care for residents who died during the 6-month follow-up period. RESULTS: Of the 205 residents in the study sample, 107 were randomly assigned to receive the intervention, and 98 received usual care. Intervention residents were more likely than usual care residents to enroll in hospice within 30 days (21/107 [20%] vs 1/98 [1%]; P<.001 [Fisher exact test]) and to enroll in hospice during the follow-up period (27/207 [25%] vs 6/98 [6%]; P<.001). Intervention residents had fewer acute care admissions (mean: 0.28 vs 0.49; P = .04 [Wilcoxon rank sum test]) and spent fewer days in an acute care setting (mean: 1.2 vs 3.0; P = .03 [Wilcoxon rank sum test]). Families of intervention residents rated the resident's care more highly than did families of usual care residents (mean on a scale of 1-5: 4.1 vs 2.5; P = .04 [Wilcoxon rank sum test]). CONCLUSION: A simple communication intervention can increase rates of hospice referrals and families' ratings of end-of-life care and may also decrease utilization of acute care resources.