Project ID: 3.g.i
Project Name:
Palliative Care
Project Description:
Integration of palliative care into the Patient Centered Medical Home (PCMH) model
Project Chairs:
Laurie Neander, At Home Care
Objective:
To increase access to palliative care programs
Rationale and Relationship to Other Projects:
Per the Center to Advance Palliative care:
“Palliative care is specialized medical care for people with serious illnesses. It is focused on providing patients with relief from symptoms, pain, and stress of a serious illness—whatever the diagnosis. The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work together with a patient’s other doctors to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment.”
Source: Building Hospital Palliative Care
Increasing access to palliative care programs for persons with serious illnesses and those at end of life can help ensure care and end of life planning needs are understood, addressed and met prior to decisions to seek further aggressive care or enter hospice. This can assist with ensuring pain and other comfort issues are managed and further health changes can be planned for.
Core Components:
Performing provider systems that have identified a need for palliative care services may choose one of the three palliative care programs as a primary service. They may chose components of the other two programs to facilitate their program. This project develops palliative care services within primary care settings.
Performing provider systems will be required to do the following steps:
- Identify appropriate primary care practices, preferably already using the PCMH model, who are willing to integrate Palliative Care into their practice model. If practices are not in the PCMH model, they will be expected to achieve at least Level 1 of the 2014 standards within the first two years of the project. Provider systems may consider this as a service in a Medical Village in association with the primary care practice.
- Develop partnerships with community and provider resources including Hospice to bring the palliative care supports and services into the practice.
- Develop/adopt clinical guidelines agreed to by all partners including services and eligibility. This should include implementation, where appropriate, of the DOH-5003 MOLST form, the only authorized form in NY for documenting both nonhospital Do Not Resuscitate and Do Not Intubate orders. Engage staff in trainings to increase role-appropriate competence in palliative care skills.
- Engage with Medicaid Managed Care to address coverage of services.