Four Seasons Pilots Medicare Reform through Innovative Community Palliative Care Model

August 25, 2015

WCMS CEO Miriam Schwarz recently met with Janet Bull, MD, CMO of Four Seasons Compassion for Life, to learn about new innovations in community – based palliative care delivery and payment models.

Last year, Four Seasons Compassion for Life was awarded a grant by the federal Center for Medicare and Medicaid Innovation to implement health care payment reform over a three year period. Four Seasons, a non-profit agency in Flat Rock, NC, was the only hospice and palliative care provider nationwide chosen for this award. In collaboration with the Palliative Care Center and Hospice of Catawba Valley, Newton, Four Seasons will test a new model for community-based palliative care across the continuum of care spanning in-patient and outpatient settings. 
An estimated 8,000 Medicare beneficiaries and their families will receive integrated health services in western North Carolina through the project. Of these, 78 percent will receive care through Four Seasons, and 22 percent will receive care through Palliative Care Center and Hospice of Catawba Valley. The goals of the pilot are to improve outcomes, increase the quality of care, and decrease hospital readmissions while decreasing costs for patients and families during serious illness or at the end of life. The project must be replicable and scalable to different communities in order to be considered a success.
According to Janet Bull, MD, Chief Medical Officer of Four Seasons, community-based palliative care differs greatly from the way care is currently delivered. Most palliative care programs are based in the hospital because of limited reimbursement. Says Dr. Bull, “Studies clearly demonstrate that palliative care reduces overall costs, but our current reimbursement structure doesn’t allow us to sustain these services outside of the hospital. Palliative care in the fee for service model doesn’t operate with a positive margin, so hospitals, healthcare systems, or hospices have to absorb the costs.” One of the primary purposes of this pilot study is to recommend to the Center for Medicare Services new payment structures for palliative care that financially support palliative care provided in the community as well as the hospital. 
With the focus on community, palliative care will be provided to patients wherever the patient goes: nursing homes, outpatient clinics, assisted living facilities, and even in the patient’s home. Dr. Bull emphasizes that, “continuity of care across these various settings is critical.” Mark Hendrix, Director of Palliative Care Operations, notes that “these new continuity of care processes must be patient-centered and efficient in order to be effective.” Dr. Bull adds, “Continuity is particularly important for the sickest 1% of the population. We plan to touch these people before they leave the hospital and shepherd them out into the community to make sure the transition of care is complete, and necessary services are provided.”
In addition to integrating palliative care across various community-based settings, the model features interdisciplinary collaboration.  Palliative care staff will keep in close contact with these patients, insuring medication reconciliation and checking in regularly to identify psychosocial and medical issues. Each team will consist of a physician, nurse practitioner or physician assistant, social worker, chaplain, and administrator. 
Breaking down traditional barriers to care, such as location, socio-economics, ethnicity/minority status, and fragility of medical condition, will also be addressed by this pilot. For example, notes Dr. Bull, “Some people are just too sick to get out of their house, and others are unable to get transportation.” For these types of patients, tele-palliative health care consults will be available, as will home-based consultations. End-of-life decisions will be approached in a culturally appropriate way. Says Dr. Bull, “We will engage in a program called Culturally Appropriate Education to Reduce End of Life Disparities. We plan to focus on advance care planning in the African American community.” Health literacy is key to patients and their families understanding their options. Patient-family advisors are being employed to represent the voice of the patient and family. Patients and their families will be taught how to engage with providers and how to manage their own care. 
Population health management is another feature of this pilot. “Our goal is to include over 8,000 patients in our population,” says Dr. Bull. Population management occurs via electronic health record management (E.H.R.). The E.H.R. pulls patient data into a “dashboard” that displays which patients are scoring high on key indicators that need to be addressed, such as pain and psychosocial issues. This allows the palliative care teams to identify and bring resources to patients who are the sickest and have the biggest needs. 
Clinical and financial results of the project will be monitored through partnership with Duke University.  Dr. Bull reports that, “Researchers will be using propensity scoring to examine cost and quality data from this pilot compared to matched controls. The findings will translate into proposed new Medicare finance models across the continuum of care to assist Medicare beneficiaries who struggle with advanced, life-limiting illnesses.” The data generated will also provide national benchmarks for other palliative care organizations to improve patient outcomes. 
To date, 500 patients have been enrolled in the program from Pardee, Park Ridge, skilled nursing facilities, and clinics, focusing initially on Buncombe and Henderson counties. The total catchment area includes the following counties: Henderson, Buncombe, Transylvania, Jackson, Haywood, Swain, and Macon. Within the next month, Catawba Palliative and Hospice Care will go live. There are five nurse practitioners who will see patients in this and surrounding counties. In May, Four Seasons plans to pilot test tele-palliative consulting services in partnership with CCWNC to assist patients and providers in outlying counties.
If you are a physician in Western North Carolina who would like to refer a patient to this program, here’s what you need to do. First, determine if the patient is eligible for palliative care. The screening criterion involves asking yourself “Would I be surprised if this patient died in the next year?” If the answer is no, then your patient is likely appropriate for palliative care.  There are other criteria that Four Seasons will consider, such as multiple co-morbidities and hospitalizations.  To get started, please call the Response Center at (828) 233-0387 to refer your patient to the program.
About Four Seasons
Four Seasons Compassion for Life is a 501c3 non-profit organization with a dedicated team of health care professionals, social workers, spiritual care professionals and volunteers deeply committed to its mission of co-creating the care experience. Nationally known for its leadership in innovative, quality hospice and palliative care services, Four Seasons is a former Circle of Life award recipient from the American Medical Association. For more information, visit