Specific standards matter, like availability around the clock of palliative care provider staff.

—Established program representative

In this section:

• A1: Eligibility criteria
• A2: Qualifications, certifications, and training for PC provider organizations and staff
• A3: Required services
• A4: Program operational processes between providers and the MCP, including reporting requirements
• A5: Payment model and amount
• Progress in California

A1: Eligibility criteria

Specify the criteria for program entry and graduation.

• Minimum: Use the minimum eligibility criteria in the California Department of Health Care Services (DHCS) All-Plan Letter, including general criteria, eligible diagnoses, and disease-specific criteria.
• Enhancements: Adjust criteria to expand access to palliative care and increase enrollments by adding eligible conditions or relaxing disease-specific criteria.

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A2: Qualifications, certifications, and training for PC provider organizations and staff

The MCP uses established criteria for excellence to select provider partners to deliver high-quality care. Provider organizations use the standards that come with certification to define their model of care and to monitor their approach.

• Minimum: Specify the minimum level of training required for PC provider staff or minimum amount of organizational experience with delivering palliative care.
• Enhancements: Require that PC providers be certified or accredited in palliative care by The Joint Commission, Community Health Accreditation Partner, or Accreditation Commission for Health Care, or require that this certification/accreditation be obtained within a specified period. Similarly, plans could require that individual provider staff be certified for disciplines where certifications are available (physicians, nurses, social workers, chaplains).

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A3: Required services

Clarify expectations for care model and staffing, frequency of contact, and other aspects of care delivery, ensuring the program is appropriately differentiated from hospice.

• Minimum: Specify expectations for service delivery, including allowable mode of contact (in-person, phone, video visits). Consider defining different service tiers based on patient acuity and needs. Tiers could come with different payment levels or not.
• Enhancements: Add services that meet additional patient family needs (such as caregiver support, 24/7 availability, spiritual care).

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A4: Program operational processes between providers and the MCP, including reporting requirements

Plans provide templates and mechanisms for reporting information and communication between the MCP and PC provider partners. Data include information about enrollments and disenrollments, documentation of services, and methods for submitting claims and/or invoices, as appropriate. (Note that quality measures are addressed separately in Section E on quality improvement and program growth.)

• Minimum: Specify required information, format, reporting frequency, and mechanism.
• Enhancements: Regularly review reporting requirements with contracted providers to ensure minimum reporting burden while meeting requirements.

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A5: Payment model and amount

In addition to paying for core services, consider PC provider time and resources needed for program management activities like data collection and reporting, and participation in meetings.

• Minimum: Use case rate payment that accounts for time invested by all PC provider interdisciplinary team members.
• Enhancements: Ensure that payment covers the range of PC provider efforts (e.g., a comprehensive assessment before enrollment, support for extraordinary needs of individual patients). Add incentive payments for meeting or exceeding performance benchmarks in activities of care (e.g., advance care planning, avoiding hospitalizations, meeting patient experience survey goals).

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Progress in California

In a March 2021 survey by CHCF and the Coalition for Compassionate Care of California, 13 of 17 MCPs (76%) reported expanding their program’s criteria beyond the minimum requirements established by the state. These MCPs either added more eligible medical conditions to the four required (congestive heart failure, COPD, advanced cancer, liver disease) and/or relaxed the disease-specific criteria for the four required conditions.

This survey also found that over half of responding MCPs require their palliative care provider partners to be certified by The Joint Commission or Community Health Accreditation Partner.

To find the best palliative care partners, ask local hospitals and specialists which providers in the community they trust with their patients.

—Established program representative