In New Jersey, a partnership between a health services company and a nursing home is offering a new approach to long-term illness, tailoring palliative care treatment plans to individual patients.
Samaritan Health Services Partners, a not-for-profit complex illnesses company, and Laurel Brook Rehab, a 220-bed facility in Mt. Laurel, New Jersey, have joined together to offer chronic illness support to Laurel Brook patients.
Kate Bauer, the regional director of marketing development for Marquis Health Consulting Services, representing Laurel Brook, describes the Chronic Illness Support model as disease-specific education and health coaching for patients and their families. The goal is to give patients and their families a more complete understanding of treatment options and goals resulting in improved quality of life, according to Bauer.
According to Dr. Stephen Goldfine, chief medical officer at Samaritan, the model emphasizes imparting truthful, practical information, allowing patients to make more informed decisions.
“As we’re trying to look at these patients, [we’re] really developing a plan that will be truthful, be honest as much as we can with the patient, so they understand where they are within that plan of care,” Goldfine said. “And then using palliative care support to identify the goals to provide things like advance care planning, where we’re trying to take the disease process and let the family and patients know what that might look like.”
Goldfine uses dementia patients as an example of a subgroup that can benefit from the Laurel Brook program.
Clinicians have a finite window to learn patients’ preferences and wishes for their care. Too often, the conversation is delayed, eliminating the patient as a reliable resource. The result: The patient’s family is left to figure out what their loved one might want.
In medicine, doctors follow a diagnosis/treatment model, Goldfine said. But understanding what the patient wants to achieve through treatment sometimes gets left out.
For example, a person with advanced cancer might have a grim prognosis, but their goal is to return home. The doctor and patient can discuss how to achieve that goal despite the longer-term prognosis, he said.
The partnership between Laurel Brook and Samaritan is a natural fit, Bauer said, having worked with Samaritan previously.
“Samaritan is in all of the hospitals that we work with, so given the great reputation that Samaritan has and the ease of us working at the same hospitals, it made sense to partner since we’re both seeing patients from the same places,” Bauer said.
Determining eligibility for the palliative program is a complex process, requiring multiple interviews and face-to-face work with the patients. If a prior palliative care referral from a hospital exists, this continues at Laurel Brook. Otherwise, nurses at Laurel Brook do an initial assessment to determine who is appropriate for the program. According to Bauer, anyone with eyes on the patient, from nurses and doctors to food service workers, has a role in the evaluation.
Patients are then referred to Samaritan for further evaluation and development of a treatment plan. The process is painstaking and while some criteria – disease type and number, for example – can fall into a spreadsheet, no universal evaluation checklist that works for everyone currently exists.
“And at the end of the day, I think that the providers actually know their patients better than any checklist can know. And I think that really has carried it,” Goldfine said.
The goal for both institutions is to improve the quality of care and quality of life for patients. At Laurel Brook, some patients are long-term residents. Others pass through rehab and are moved back into the community. The Chronic Illness Support model is designed to follow those patients back to their home and continue the palliative care.
The response from chronically ill patients introduced to the support model has been positive, Bauer said. Clinicians explain the program, aiming to ease patients’ anxieties and define end-of-life and serious illness care terms – with the difference between hospice and palliative care a big one to cover.
That definition has made a difference in how the model is accepted, she said.
“Samaritan reaches out to those families before seeing the patient to explain what the palliative care program is about, to make sure that they’re on board and they’re OK with it,” Bauer said. “So they do their due diligence prior to seeing the patient. And that, I think, has been very successful.”
Right now, Samaritan relies on fee-for-service. The company received some funding from the state of New Jersey to fund the social worker portion of the Chronic Illness Support model. The company is open to taking part in value-based programs such as Medicare Advantage plans, Goldfine said.
“We are open for value-based, and we’d love to work with the Medicare Advantage programs, any of the ACOs, I think that we are open for that and we have some experience doing that,” he said.
According to Goldfine, palliative care is generally under-reimbursed, in part because it relies so much on communication and goal-setting, both time-consuming endeavors.
“And that’s why I think value-based in the future is really going to help palliative care provide a high level of care for these patients,” he said.
Bauer said the program has been well-received by Laurel Brook staff, who see chronic illness support as another tool to use in developing treatment plans for patients.
“The hospitals all are appreciative that we have this program,” Bauer said. “There aren’t any other skilled nursing facilities in our area that offer this type of program, and everyone’s goal is to keep the patients healthy and get them home safely. And this program has really helped us facilitate that, and the hospitals are appreciative of that also.”
