8. Integration

Palliative care should be integrated with other medical and social programs that serve people with serious illness, to streamline care for patients and to ensure people who would benefit from palliative care can access it at the right time. Integration can occur at varying levels, from intentional cross-organizational collaboration aimed at promoting identification of people who would benefit from palliative care to formal colocation and partnership, such as embedding a palliative care team within a specialty oncology practice. Integration can support the impact and sustainability of palliative care through:

• Increased uptake. Providers can facilitate patients’ use of PC services by integrating palliative care into settings where people are already receiving care, such as specialty outpatient clinics and primary or acute care in the home. See more information under Opportunity 2, “Uptake.”
• Care customized to patient needs. Positioning PC as one of several tools available to improve care of seriously ill people enables providers to customize services to align with patient needs more effectively. If PC services operate in close collaboration with home-based primary care, care management programs, disease management programs, and similar services, patients can more easily transition to the type of support that best meets their needs at a given time. Such versatility anchors service delivery in patient and family needs and likely helps avoid over- and underserving patients.
• Increased awareness of PC as the standard of care. Normalization of PC occurs for both other treating providers and for patients by establishing access to PC as the standard of practice within a given setting. Patients can be instructed to expect consultations with PC as a common procedure in the clinic, thus eliminating the potential for patients to misconstrue a PC referral as indicative of a limited prognosis. Similarly, other treating clinicians can reliably expect engaging with PC as a part of their routine, mitigating the risk of providers incorrectly assessing the best timing for referring to PC, which can result in late or no referral.

“Integration makes palliative care more effective for the patient, rather than being just one more fragment in a fragmented system.”

—Coalition for Compassionate Care 2023 Annual Summit participant

Action: Embed palliative care within other inpatient and outpatient services and settings.

Positioning palliative care teams to deliver care alongside other treating clinicians carries many potential benefits. This strategy has been tested in primary care practices, specialty disease clinics like oncology, and in hospital areas with high concentrations of seriously ill people such as emergency departments and intensive care units. The goal is to make it easier for people to access palliative care and to reduce the barriers to identifying and referring patients. PC programs that have tried embedded palliative care report that non-palliative care providers are accepting of the services and can see improvements in patient care. Some studies have documented clinical, operational, and economic benefits for health systems related to embedded PC services.

Action: Integrate palliative care with Medi-Cal’s Enhanced Care Management services.

The CalAIM (California Advancing and Innovating Medi-Cal) policy guidance for Enhanced Care Management (ECM) explicitly states that the comprehensive health assessment conducted as part of ECM should include a screening process for assessing the need for palliative care. Some populations eligible for ECM, particularly frequent users of health services, likely qualify (or will qualify) for palliative care. To facilitate optimal coordination between ECM and palliative care providers, health plans and palliative care provider organizations can undertake the following steps:

1. Train ECM providers to educate members on the value of palliative care, and how and when to communicate with plan partners that a member might benefit from palliative care. This training should include the health plan’s palliative care provider partners to help organizations get to know each other.
2. Train palliative care providers on ECM, and similarly involve ECM providers in the training.
3. Enable the exchange of data and care plans between ECM providers and palliative care providers.
4. Document integration efforts to ensure consistency going forward, given inevitable staff turnover.

Also, intentionally linking palliative care with ECM and other CalAIM programs will help maintain visibility and relevance as new programs, policies, and requirements are introduced. Looking ahead, palliative care champions, both within and outside health plans, should work toward establishing connections between palliative care and other plan programs. They should also show how these linkages bring mutual benefits.

“It has been really important to build a continuum of services in all places for a patient and follow a person throughout their care experience. We know that people facing serious illness have more transitions and are more likely to go back and forth to different specialists. I think that one of our biggest successes is creating serious illness care and specialty palliative services across all settings, so that we have the ability to meet the patient where they are in their life journey.”

—Susan Elizabeth Wang, MD, National Medical Director, Dignified Journeys & Palliative Care; Southern California Chief, Geriatrics & Palliative Medicine, Kaiser Permanente

Action: Integrate palliative care with home-based medical services.

Providers of palliative care services should consider ways to integrate with other home-based medical services such as home-based primary care and hospital-to-home transitional care programs. People who are homebound and already receiving primary or transitional care in their homes likely would also benefit from specialty palliative care.

Actions for Stakeholders

Learn more about each action (PDF), including how all stakeholders can commit to this opportunity.

For full source information, see California’s Palliative Care Evolution — Opportunities to Further Advance Palliative Care in California (PDF).