We removed the requirement for a physician gatekeeper as the only person who could refer. Now anyone can refer a patient to us.

—Established program representative

In this section:

• D1: Processes for MCP internal case finding
• D2. Education and engagement for high-value external referral sources
• D3. Processes for member engagement and education
• D4. Educational materials for MCP members and families
• Progress in California

D1: Processes for MCP internal case finding

Strategies include internal referrals from other MCP programs that support members with serious illness, case finding using risk stratification tools, and data reports from claims, encounters, authorizations, and pharmacy.

• Minimum: Specify processes for identifying eligible members through referrals from other MCP programs and from analysis of diagnoses and utilization data such as hospitalizations and emergency department visits.
• Enhancements: Create palliative care–specific reports that combine different data sources, or use predictive modeling to identify members who might benefit from palliative care. Create referral volume goals for MCP case managers or other key staff.

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D2: Education and engagement for high-value external referral sources

Promote program with high-volume, high-value referral sources including hospital-based PC providers, hospital discharge planners and case managers, specialty care medical groups, and community organizations that serve Medi-Cal enrollees with serious illness.

• Minimum: Create and disseminate materials written for health care and social services professionals that describe PC. Create patient-facing materials for these partners’ patients/clients, in multiple languages to support equitable access. In these materials, distinguish palliative care from hospice and describe how PC aligns with other MCP and community-based services.
• Enhancements: Meet regularly with the individual professionals at these high-value referring partners who serve seriously ill MCP members. Use these meetings for ongoing relationship management and monitoring of the progress of these partnerships.

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D3: Processes for member engagement and education

Where prior relationships exist, the MCP member/patient is introduced to palliative care by that MCP staff person or the community provider. This person with an existing relationship explains the PC program and its benefits, and then facilitates a warm handoff to the PC organization.

• Minimum: Orient MCP staff to palliative care as a specialty health care service, and to the MCP’s own program specifically, so staff are prepared to discuss PC services with members.
• Enhancements: Establish warm handoffs as a standard expectation for all MCP members starting PC, and create a performance metric to track success. Provide in-depth training to MCP staff to increase comfort discussing palliative care with members and their families.

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D4: Educational materials for MCP members and families

MCPs and PC providers collaborate to develop clear, accessible materials to promote the program and clarify the who, what, and why of PC. Information is distributed through websites and in printed form, at the required Medi-Cal reading level and in the MCP’s threshold languages.

• Minimum: Develop print materials and web content for MCP members, with clear and simple language to describe how PC supports patients and families while patients are treated for their disease. Clearly distinguish palliative care from hospice.
• Enhancements: Increase awareness of PC and the MCP program among community-based organizations serving seriously ill people in the Medi-Cal population, including providers in the MCP’s Health Homes and Enhanced Care Management programs.

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Progress in California

In a March 2021 survey by CHCF and the Coalition for Compassionate Care of California, a shared priority for the next year for both MCP respondents (at 89%) and PC provider respondents (at 71%) was to increase program enrollment. The chief concern related to program sustainability for both MCPs and PC providers was too few patients/members.

The top two barriers to a successful program, according to the PC provider respondents, were “PCP unwillingness to introduce/recommend palliative care” (at 77%) and “too few referrals” (at 74%).

To build referrals, patient stories are the most effective. To make it fun, we use a ‘Who is eligible?’ quiz in sessions with referring groups.

—Established program representative

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