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Advanced Illness Partners, A new Hospice Value-based Care Model

By Ned Stolzberg, MD, Executive Medical Director at Hospice of the Valley
Photography courtesy of Hospice of the Valley

Fall 2021

Healthcare is quickly evolving these days and providers; hospital groups and private and government health plans are all looking toward value-based care as a way to improve outcomes and lower cost. Over the past several years, a variety of value-based programs and ideas have been implemented across the spectrum of healthcare that share the same goal: To shift the incentives in healthcare from those driven by volume to those driven by outcomes and quality.


A common tenet of value-based care is flexibility. Typically, providers are paid a set monthly amount to oversee care of a patient. When the care results in savings, those savings are shared with the physician. Conversely, the physician also may bear part of the risk if outcomes are not as hoped. Care is determined by patient need and is not limited to provider office visits. Physicians can determine which patients need the most “touches” and what those encounters should be. Patient management can move beyond the traditional office visit and could encompass a variety of innovative strategies: telehealth, group education, use of health coaches, involvement of community resources, etc. Such a model allows for creativity and empowers each member of the healthcare team to function at their highest level of skill and training.


Bringing Hospice Providers Together

One of the most promising populations for whom value-based care could have a dramatic impact is people living with long-term chronic diseases, especially those who are geriatric or have significant social factors that impact their healthcare. Often, such patients have challenges accessing and navigating the healthcare system, resulting in poor control of their illnesses and subsequent frequent hospitalizations. Addressing their needs through a multimodal and wide-ranging approach can interrupt the negative feedback loop of fragmented care that leads to emergent hospital stays and further fragments care. Managing patients comprehensively and proactively in their homes is just good medicine.


Hospice of the Valley is one of seven nonprofit healthcare agencies nationwide that have come together to offer an innovative value-based program to care for people with complex chronic illnesses. The joint venture, Advanced Illness Partners or AIP, is part of a six-year pilot study commissioned by the Centers for Medicare and Medicaid Innovation. Besides Hospice of the Valley, the other nonprofit partners include: Hope Healthcare, Housecall Providers, Cornerstone Hospice, Nathan Adelson Hospice, Capital Caring Health, and Pure Healthcare, which is part of Ohio’s Hospice, a group of 10 affiliated providers located throughout that state. 


Combined, these seven providers care for nearly 60,000 patients each year. Recognized as leaders in the field of value-based care, they create innovative programs that lower cost, but improve the care of high-needs patients with complex illness. Costs to start the venture are relatively modest and primarily relate to contracting for data analytics.  Much of the infrastructure for care is already in place as a result of the hospice and palliative programs managed by AIP member organizations. AIP will receive a risk-adjusted monthly payment for eligible patients and will share risk for 50% of shared savings or losses for Medicare Part A and B services.


The top priority of AIP will be to deliver cost-effective, high-quality, primary care to patients with advanced disease who find it difficult to visit a doctor or access the healthcare system. Hospice of the Valley provides this comprehensive care to our community through Geriatric Solutions, a practice that brings primary care to home-limited patients throughout Maricopa County. The AIP project now enables the physicians and nurse practitioners working with Geriatric Solutions to marshal the resources Hospice of the Valley uses for hospice and palliative care patients for the benefit of a primary care geriatric population. 


AIP Model Benefits

In the 20 years I worked in a private family practice, I cannot tell you the number of times I wished I had readily available social work or nursing resources for my patients who would come with problems that went well beyond what I could offer them as a physician. Patients cared for under the AIP model can take advantage of all these services and more. Those who would benefit most from social worker services can obtain them. Those who need nursing visits can have them. Ongoing education on disease management for patients and caregivers alike can be provided by respiratory therapists, dementia counselors and a variety of nurse specialists. When faced with a crisis in the middle of the night, patients can speak with a registered nurse (not an operator or an answering machine), who triages the concern and even sends a nurse if needed. All patients have access to this 24/7 support. 


This program provides a large safety net to help keep these vulnerable patients from slipping through the cracks of the medical system. The team-based approach is comforting to a population that often feels alone and anxious. Having a specialized team come to them is an enormous boost to both body and spirit.


It is exciting to be able to offer a service aimed at providing care best suited to an individual patient when and where they most need it. We are confident this innovative approach to home-based primary care will result in fewer hospitalizations, significant cost savings and, most importantly, better care for some of our community’s most fragile patients.

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