Provider Engagment

Value to the Medical Home

The Palliative Illness Management™ (PIM)™ solution supports patient centered medical home goals and acts as a natural extension of primary treating physician offices. The PIM™ community-based palliative care teams focus on improving patient / caregiver / provider communication, while establishing goals of care, identifying gaps in care, and minimizing chances of unplanned care. Working with physicians to achieve medical home goals, palliative care teams help avoid over-medicalization and allow patients to age at home. This home-based collaborative model builds stronger physician/patient relationships, while improving reach and frequency of patient and caregiver engagement.

Streamlines Physician Care Processes

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Clinician-led teams create a palliative plan of care based on patient goals, with ongoing home-based support, patient education and assistance with medical decision-making. When issues arise related to symptoms or prescriptions, safety concerns or changes in goals of care, the nurse or social worker directly contacts the patient’s physician. In the Turn-Key model, these professionals document comprehensive palliative assessments and follow risk-based care pathways and care management protocols to better match care delivery to patient/family needs. They are responsible for arranging for social support services, addressing other non-medical needs and following patients through the course of their illness unless they stabilize and no longer require services. Palliative care specialists aim to keep patients healthier outside the hospital, providing regular, routine home visits and phone outreach that will help to avoid emergency room visits, hospitalizations or readmissions, and ICU stays.

Support for Advance Care Planning

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Despite the many benefits of advance care planning, many primary care providers feel ill prepared to deliver these services. Fortunately, the Turn-Key Health professional palliative teams are specially trained to provide this support, articulating goals of care, scaling the frequency of care into the home, and enhancing communication with the member.

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With the experience and expertise to conduct difficult conversations around goals of care, specialized palliative care professionals match the patient’s personal wishes with treatment options.

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Physicians benefit when these additional levels of attention and dedicated resources are in place. They place high value on simplifying opportunities to reach the patient more effectively and coordinating treatment options that take into account their initial care recommendations.