In this section:

• B1: Well-prepared interdisciplinary team
• B2: Standardized model, processes, and tools for patient care
• B3: Operational and administrative processes
• B4: External awareness and understanding of palliative care
• Progress in California

B1: Well-prepared interdisciplinary team

Establish an interdisciplinary team (IDT) with appropriate clinical skills and training for provision of high-quality PC.

• Minimum: Clinical team should include physician / advanced practice nurse / nurse practitioner (as clinical director or provider of direct care, or both), nurse, social worker, and spiritual care professional. Ideally, all clinical team members have current professional certification for PC; at minimum, they have completed training in core PC clinical skills, including:
  • Recognizing, assessing, and managing physical and emotional distress
  • Discussing goals of care
  • Conducting advance care planning and completing documentation (health care proxy, advance directive, POLST) where appropriate
  • Connecting patients and families to other health care and social needs resources like substance use treatment, mental health care, housing, financial supports
• Enhancements: Include the role of community health worker or outreach specialist on the care team. Seek and secure organizational certification in palliative care from an accrediting body. Ensure current professional certification for PC for all IDT members where such certification exists for their discipline. Support additional training in:
  • Communications skills and difficult conversations
  • Anticipating and managing crises
  • Identifying and managing support needs of caregivers and family members

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B2: Standardized model, processes, and tools for patient care

The provider defines a consistent but flexible patient-centered approach to assessing and addressing patient and family needs. 

• Minimum: Identify standard approaches and tools for intake, initial and ongoing screening and assessments, development of the care plan, and documentation of care, with clear roles and responsibilities for different team members.
• Enhancements: Cross-train staff in different aspects of care to allow for more flexibility, capability, and capacity to identify and respond to patient needs. Define triggers for engaging other team members. 

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B3: Operational and administrative processes

The provider establishes clear processes that support team readiness, internal and external communication, and administrative functions supporting the MCP-provider partnership. The team refines these processes over time as the program grows and evolves.

• Minimum: Define team member roles and responsibilities, and clinical documentation expectations. Develop processes for team communication, internally for real-time clinical management and externally for communication with MCPs, referring providers, and other treating providers. Establish clear processes for managing MCP authorizations, submitting claims, and monitoring payments.
• Enhancements: Define standards for in-person care versus care by video or phone. Establish clinical quality targets. Define a routine process and forum for performance monitoring and ongoing improvement efforts.

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B4: External awareness and understanding of palliative care

The provider organization promotes its palliative care services, with separate materials and approaches for health care professionals (referring providers, other treating providers) and patients and families.

• Minimum: Create materials (both print and web-based) for both audiences that clearly describe (1) what palliative care is (using language that clearly differentiates PC from hospice), (2) how it can help, (3) information about the PC provider organization, and (4) how to seek services.
• Enhancements: Collaborate with MCP to conduct educational sessions with high-volume, high-value referral sources including hospital-based PC providers, hospital discharge planners and case managers, specialty care medical groups, and community-based organizations that serve people with serious illness. Distinguish palliative care and hospice in all aspects of the PC provider organization, including marketing, staff roles, and services. This could mean separate phone lines for palliative care and hospice, or even rebranding and renaming the organization.

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Progress in California

A March 2021 survey by CHCF and the Coalition for Compassionate Care of California found 71% of provider organization respondents (22 of 31) with active MCP contracts are certified by The Joint Commission (TJC) or Community Health Accreditation Program (CHAP). An additional 13% (4) plan to seek accreditation soon. Of the MCP survey respondents, 53% (10 of 19) require TJC or CHAP certification.

Offering palliative care has helped our agency grow as a whole. It helps that we can also directly bring on our own home health team or hospice.

—Established program representative

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