A: Define (or refine) the MCP program
The Medi-Cal managed care plan (MCP) defines the core elements of its palliative care (PC) program, including patient eligibility, required services, and provider performance standards. Ideally, the program elements are developed in collaboration with contracted or potential PC provider partners, to bring their expertise to bear on program design. Once the basics are established, partners then negotiate (or renegotiate) mutual performance expectations and payment.
“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.
Tools and Links
Department of Health Care Services palliative care program web page. Includes a description of the authorizing legislation for Medi-Cal palliative care, the All-Plan Letter with program requirements, other related documents, and a simple diagram placing the state program in the context of palliative care, advance care planning, and hospice.
Palliative Care Program Expanded Eligibility and Graduation or Disenrollment Criteria (PDF) (CHCF compilation of MCP resources).
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).
Tools and Links
Credentialing recommendations for programs and clinicians (Center to Advance Palliative Care [CAPC] Serious Illness Quality Alignment Hub).
Palliative care program certification: national quality standards and links to five program certification options from four national organizations — The Joint Commission, DNV GL Healthcare, Community Health Accreditation Program, and Accreditation Commission for Health Care (CAPC).
Clinical quality information and available certifications for individual clinicians for four staff roles (physicians, nurses, social workers, chaplains) (CAPC).
Requirements for Credentialing and Training for Palliative Care Providers (PDF) (CHCF compilation of MCP resources, also listed in Section B1).
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).
Tools and Links
List of state-required services (PDF) in a community-based palliative care program (All-Plan Letter 18-020, DHCS, December 7, 2018).
“Telemedicine for Health Equity.” Key considerations, expert advice, and examples of how to integrate telemedicine into all types of primary care services (Center for Care Innovations).
Service Tiers and Additional Services, examples (PDF) (CHCF compilation of MCP resources).
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.
Tools and Links
Reporting Requirements and Templates, examples (PDF) (CHCF compilation of MCP resources).
Enrollment summary spreadsheet (ZIP) to capture numbers of members referred, members eligible, members enrolled, and other dispositions (CHCF, also listed in Section E2).
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).
Tools and Links
“Payment Issues” (PDF), in Lessons Learned from Payer-Provider Partnerships for Palliative Care, a brief report with four guiding principles (CHCF).
Payment Models in Medi-Cal Palliative Care Programs (PDF) (CHCF compilation of MCP resources).
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
Authors & Contributors
Hunter Gatewood
Hunter is a consultant and teacher in leadership and improvement with his company, Signal Key Consulting. His connection to palliative care stems from experience in social work case management with high-mortality populations, and more recently in serving palliative care providers in quality improvement and systems integration efforts.
Kathleen Kerr
Kathleen is a health care consultant in private practice in Northern California. Her work is focused on promoting the development of sustainable, quality palliative care programs, with particular emphasis on services that operate in rural areas and those that serve Medicaid enrollees.
