Patients suffering from a terminal diagnosis often find they have a variety of options for care at the beginning of treatment and near the end of life. Often patients fall into a gap during the midpoint of treatment when they are looking for ways to deal with symptoms of their illness or side effects of medicine.

When patients fall into that gap, often it means added trips to an emergency room, increasing costs and aggravation. A pilot project by the Health Plan of San Joaquin (HPSJ) hopes to address that gap through a palliative care program.

“The program provides supportive care for chronic conditions,” said HPSJ Chief Medical Officer Lakshmi Dhanvanthari, MD. “The program focuses on when the patient is still getting curative care.”

Unlike, hospice care which focuses on helping patients deal with end-of-life issues, palliative care focuses on family-centered care that improves quality of life duringtreatment.

A series of nurses and social workers meet with patients to help anticipate, prevent and treat suffering. The program works throughout the continuum of illness to address physical, intellectual, emotional and social, as well as spiritual, needs. So far, about 70 members are enrolled in the program.

“Palliative care usually starts when you think the patient has about a year to live,” Dhanvanthari said. “It helps the patient to understand their illness better.”

The HPSJ program focuses on patients with end-stage liver disease, advanced cancer, end-stage congestive heart failure and end-stage chronic pulmonary disease.

“Our patients have very advanced illnesses,” Dhanvanthari said.

One of the big differences between this program and others is its focus on helping patients beyond the hospital. The program offers in-home consultation, and patients can call a team member 24-hours-per day. Health Plan of San Joaquin has also teamed with local agencies to expand local care expertise and capacity for palliative care in both San Joaquin and Stanislaus counties.

“These services help them better manage their symptoms,” Dhanvanthari said.
One of the biggest goals of the program is to keep patients from having to make return trips to the hospital. By giving patients more information, they can often find remedies to symptoms or side effects of treatments that don’t require hospitalization.

“The palliative care team explains the patient’s options,” Dhanvanthari said. “How do you prevent some of these side effects from happening? Who do you call? You can reach out to the palliative care team. They can help a patient decide should they go to emergency room.”

The program also works to keep patients from bouncing back once they are out of the hospital and returned home from treatment.

“Usually care is provided in the hospital setting,” said Dhanvanthari. “They go home, and they bounce back to hospital. What we are trying to do is provide community care. We go into the patient’s home and into the community.”

Health Plan of San Joaquin is funding the cost of this pilot project for clinical services. A $24,000 grant from the California Healthcare Foundation helped get through the planning stage of the program. That planning helped the program get a head start by coordinating services with San Joaquin General Hospital, Hospice of San Joaquin and Community Care Choices and the palliative care program at Community Hospice in Stanislaus County.

The program that resulted from that planning earned HPSJ a second, two-year, $80,000 grant from the California Healthcare Foundation.

Program planners elected to offer outpatient care services for HPSJ members as a head start to a larger, state-focused palliative care effort. Such care will be a new Medi-Cal member benefit starting in early 2018.

Judging the success is one of the tougher aspects of programs such as this. The patients have terminal diseases that, so often, success has to be judged by quality of life.

“I think the best success is how do we help the member live life the way they want to live,” Dhanvanthari said. “The ability to deal with such a significant issue in their life is tough. It is a really hard time. Sometimes we help them transition to hospice. We want them living with dignity in their last days of life. That is the biggest thing that is hard to measure.”

Other quantifiable measures have shown success in similar programs around the country. Aetna’s Compassionate Care Program saw an 81-percent decline in inpatient days, saving $12,000 per member. One thing that often makes the biggest difference is how soon the palliative care starts.

A 2014 study in the Journal of Clinical Oncology found that palliative intervention within six days of hospital admission reduced costs by 14 percent. When care began within two days of admission, costs were reduced by an estimated 24 percent.

“We are definitely continuing the project,” Dhanvanthari said. “This helps bring people together. This is really needed in this community.”

By Kent Hohlfeld – January 18, 2018

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