Integration of Palliative Care into the Patient-Centered Medical Home (Project 3.g.i)
What do we hope to accomplish?
- Enhance Primary Care Physicians’ competencies to integrate generalist-level palliative care in the NYP Ambulatory Care Network and community-based practices as standard of care
- Develop a new capacity to provide specialized palliative care services by expert team in the NYP Ambulatory Care Network
- Develop model of care to include care management oversight and collaboration with external providers
Who is our target population?
- Patients facing advance illnesses who have unmet palliative care needs or avoidable utilization with a diagnosis of one of six conditions: Congestive Heart Failure (CHF), Kidney Failure, Dementia, Chronic Obstructive Pulmonary Disease (COPD), Stroke, Malignancy and Sickle Cell Anemia
How will we do it?
- Enhance Primary Care Physicians’ knowledge of palliative care for further incorporation into their practice through integrated educational interventions
- Integrate palliative care screening and risk assessment within the NewYork-Presbyterian Hospital PPS to address unmet palliative care needs
- Implement a specialized palliative care team to collaborate with providers throughout the PPS and provide care management services, including:
- Employing RN Care Managers who will coordinate with other team members to conduct palliative care assessments and provide palliative care expertise to interdisciplinary teams
- Utilizing Community Healthcare Workers to enhance support to patient and families in the community through home visits and additional education
- Collaborate with PPS network members to develop referral processes for palliative care
NY State Requirements
- Integrate Palliative Care into appropriate participating PCPs that have, or will have, achieved NCQA PCMH certification.
- Develop partnerships with community and provider resources including Hospice to bring the palliative care supports and services into the practice.
- Develop and adopt clinical guidelines agreed to by all partners including services and eligibility.
- Engage staff in trainings to increase role- appropriate competence in palliative care skills and protocols developed by the PPS.
- Engage with Medicaid Managed Care to address coverage of services.
- Use EHRs or other IT platforms to track all patients engaged in this project.
Scale and Speed
Metric: The number of patients receiving palliative care procedures at participating sites, as determined by the adopted clinical guidelines.
Commitment: At the completion of Year 2, the Palliative Care Project will provide palliative care procedures to 2,565 unique patients annually.