Opinion: Extend Reach of Patient-Centered Medical Home, Enhance Physician Practice with Specialized Community-Based Palliative Care


As those age 65 and older face more serious illness, unprecedented burdens to serve a burgeoning population in need of high quality, coordinated care outside the acute care setting have emerged.

Csaba Méra, MD

Physician Consultant, Turn-Key Health


With dramatic increases in the number of people reaching age 65 and older facing serious illness, the growth of Medicare Advantage plans nationwide and pressures to reduce hospital admissions/readmissions, patient-centered medical homes and physician practices have unprecedented burdens to serve a burgeoning population in need of high quality, coordinated care outside the acute care setting.

Despite the serious setbacks to advancing palliative care on a national scale during the formative years of the Affordable Care Act, proponents who understood the need for this critical healthcare service were not deterred1. The foundational challenge of palliative care stakeholders has been to ensure that people clearly understand benefits of it.

As articulated by the World Health Organization: “Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” One of the key elements that are most often misunderstood is the fact that a patient who enrolls in palliative care does not have to stop active treatment for their underlying medical condition.2

The emergence of Community-based Palliative Care (CBPC) encompasses a variety of models of care designed to meet the needs of seriously ill individuals and their families, outside of the hospital setting. Much needed in the current healthcare environment, CBPC addresses psychosocial issues, provides symptom management and medication reconciliation, enhances care quality and care coordination, identifies caregiver needs and supports the challenges of day-to-day living, guides advance care planning, and improves quality of life for patients and families.

The CBPC model is now being adopted by patient-centered medical homes and accountable care organizations, offering some of the most innovative and impactful palliative programs. The emphasis is on addressing the comprehensive needs of the whole person and the family, respecting and honoring the wishes of the patient while avoiding burdensome, non-beneficial and costly futile care.

More recently, CBPC programs have been developed by a variety of community-based organizations across the nation, serving a wide range of patient populations by age and type of healthcare coverage. They involve collaborations among multiple community-based healthcare entities. They also provide training of clinicians and support staff on the principles of palliative care and offer the services of a support team that includes medical, social, community and psychosocial services, as well as spiritual support based on patient preference. These models offer comprehensive home-based care, and some have even developed complementary tele-palliative care services.

Caregiver Support

In fact, a study published in the New England Journal of Medicine shows that palliative care can help patients live longer. Of 151 patients with advanced lung cancer, those given early, concurrent palliative care survived 11.6 months, nearly 3 months longer than those who received standard medical care. Evidence also shows that, with or without curative treatments, a palliative approach offers the best chance of maintaining the highest possible quality of life for the longest possible time, according to the National Center for Biotechnology Information.About one-third of primary care physicians (PCPs) offer palliative care services, allaying some fears about a growing senior patient population and a shrinking palliative care workforce. This kind of reach into the home is especially important for caregivers.

While there is no required training for in-home caregivers, the responsibilities can be enormous. They can include simple things like housecleaning, laundry, and meal preparation, and they often include personal care services that can be much more challenging. For instance, the care may involve keeping track of multiple medications or providing supervision to a person who could pose a threat to his or her own well-being. Without training, the caregiver’s ability to recognize and report issues to healthcare providers and plans is limited.

Value of CBPC to the Medical Home

Because it places greater emphasis on addressing the needs of the whole person and the family, CBPC successfully expands the goals of care toward comfort and quality of life. It adheres to patient and family wishes while avoiding costly, burdensome, non-beneficial care at the end-of-life.According to the latest research, older, white, male providers in rural areas are the most likely population to deliver palliative care—a restricted clinician base that could see palliative treatment options shrink in the future. Providers practicing in or applying for patient-centered medical home certification, however, were 1.73 times more likely to deliver palliative care than those who were not associated with a patient-centered medical home.

A natural extension of the physician-led medical home, CBPC clinicians—primarily nurses and clinical social workers practicing at the top of their licenses—increase the reach and frequency of patient engagement and interaction.

CBPC is about providing a more structured approach to the medical home, streamlining reporting and communications with physicians. It provides an extra layer of support for patients and families, with field-based clinician resources that extend the reach of a high-touch physician practice rather than adding another layer of physicians providing medical care.

Value of CBPC to Physician Practices

CBPC improves care quality and enhances care coordination while supporting better patient self-management and adherence to treatment. Clinicians work with the PCP to achieve medical home goals, addressing issues related to care fragmentation, building patient relationships, and extending all of the benefits of the care practice. In this way, CBPC helps to achieve the “Triple Aim” result: improved patient outcomes, improved patient experience, and improved value. The value of a CBPC program to physician practices can be demonstrated on several levels. As a natural extension of the physician-led medical home, CBPC clinicians, primarily nurses and clinical social workers, practicing at the top of their licenses, increase the frequency and reach of patient interaction and engagement. The CBPC approach also provides a more structured approach to the medical home, streamlining reporting and communication with physicians.

It also provides an extra layer of support for patients, families, and caregivers, with field-based clinician resources that extend the reach of the high-touch physician practice rather than adding another layer of physicians providing in-office medical services. By improving the efficiency and effectiveness of care coordination for enrolled patients, it improves the quality of care through better patient self-management and adherence to treatment plans.

Through improved and more engaged experience with the patient, the practice is able to clearly understand the in-office and in-home needs of each patient and proactively arrange the specific service and care needs for each individual’s unique circumstances. Once individual patient needs are clearly identified in this collaborative approach, the physician care team is able to anticipate and address variations in specific service and care requirements and complications as they may arise.

The enhanced relationship provided by this model enables the team members to conduct those difficult conversations around goals of care, aligning with the patient’s personal wishes and appreciated by the patient and family for the caring and compassionate service that they provide.

CBPC provides relief to the busy time-pressured physician, as the palliative care skilled team coordinates the many day-to-day needs of the patient, allowing the physician to focus on the role of providing quality care and improving the quality of life for each patient. This level of support also increases the frequency of interaction with patients, while enhancing long-standing physician relationships with individuals and their families.

CBPC streamlines physician care processes, augmenting the patient-centric approach by improving care coordination, offering advance care planning, articulating goals of care, scaling the frequency of care into the home, and enhancing communication with the patient.

Physicians and patients alike benefit when additional levels of attention and specialized resources loop back to the physician’s initial care program. This approach simplifies opportunities for physicians to reach the patient more effectively, further enhancing the effectiveness of care.

Innovative CBPC Models

CBPC also frees up physicians to focus on what they do best: providing quality medical care rather than focusing on the challenges of assisting patients with the tasks of everyday living. CBPC enhances the efficiency and quality goals of the medical home, addressing care fragmentation and building stronger physician/patient relationships through the extension of all the benefits of the care practice to the enrolled population.Despite its many benefits, many PCPs feel ill-prepared to deliver palliative care services, especially advance care planning. Fortunately, some innovative CBPC models deploy local nurses and clinical social workers teams who are typically employed within local hospice and palliative care organizations. These teams document comprehensive palliative assessments and follow risk-based care pathways and care management protocols to better match care delivery to patient/family needs.

Clinician-led teams create a palliative plan of care based on patient goals, with ongoing home-based support, and provide patient education and assistance with medical decision-making. When issues arise related to symptoms or prescriptions, safety concerns or changes in goals of care, the nurse or social worker directly contacts the patient’s physician.

The CBPC specialist is responsible for arranging for social support services and addressing other non-medical needs. The team continues to follow patients through the course of their illness unless they stabilize and no longer require services.

Ultimately, this approach clearly promotes and meets the value proposition of the Triple Aim by improving patient clinical outcomes, the patient experience and the value of the care and services delivered. This extraordinary level of personalized support aligns physicians and other care teams to organize patient care activities and create seamless transitions in care that directly achieve safer, more effective care.


CBPC specialists aim to keep patients healthier outside the hospital, providing regular, routine home visits and phone outreach that will help to avoid emergency room visits, hospitalizations or readmissions, and ICU stays. The results of a 1-year program at Mount Carmel Hospice and Palliative Care, in Columbus, Ohio, validated an innovative CBPC program provided by Turn-Key Health for seniors enrolled in a Medicare Advantage plan. There were 208 members enrolled in the program, compared to 800 members who were identified by the model but not enrolled:

  • The overall reduction in healthcare expenditures was 34%.
  • Hospitalizations were lowered by 32%.
  • Hospital readmissions were reduced by 61%.
  • ICU days were reduced by 37%.
  • Earlier and appropriate election of the hospice Medicare benefit.

Results from the program also demonstrated impressive clinical results:

  • 98% goals of care completion.
  • 97% symptom satisfaction.
  • 4.8 out of 5 stars satisfaction rating.

These data demonstrate that CBPC is an ideal way for physicians to scale their reach and frequency of patient touch in the home setting.

1. Dying in America: Improving quality and honoring individual preferences near the end of life. Washington, DC: The National Academies Press. IOM (Institute of Medicine). 2015.

2. WHO Definition of Palliative Care: http://www.who.int/cancer/palliative/definition/en/


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