Advanced Illness Palliative Care Management
Mar 2012 Poster Presentation during the American Association of Case Management National Conference 2012
Despite hospice offering evidence-based outcomes, cost-effective and high quality care services, it is under-utilized due to: inadequate communication from physician team to patients and family unit about disease processes and goals of care, patient and family unit's lack of understanding of health care options and hospice benefits, and the current restrictive hospice regulatory guidance and reimbursement method. With the rising aging population and need for chronic and advanced illness management, this author proposed a case management program with goals to: improve quality of life for patients with advanced illnesses by increasing access to quality care in the community and at home, and reduce healthcare expenditures related to symptom management in an inappropriate level of care for chronic and advanced illnesses. The proposed program has two components:
A transitional care model to ensure smooth transition from hospital to the community, and
A modified home care model for advanced illness management.
The design of the proposed program is to be implemented in an integrated health care delivery system, as it encompasses inpatient setting, community setting and home-based setting. The program will benefit adults 18 years or older, diagnosed with a life-changing or advanced illness, including but not limited to cancer, congestive heart failure, and chronic obstructive pulmonary diseases, with a prognosis of 12 months or less. The unique features of the program are: transitional care interventions and home-based complex case management, linkage and coordination of care, patient education on illness trajectories, advance care planning and goals of care discussions, and facilitation of hospice enrollment if appropriate.
Keywords: transitional, home-based, palliative, case management