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Innovation Grant Funds New Model of Care for Patients with Advanced Illness

By Andrea Gresko 1/25/17

For patients in a community struggling with serious illness, palliative care services offer interventions that promote dignity, safety, and choice while improving the experience for both patients, families, and their caregivers. Yet palliative care services are often underutilized and qualified patients miss out on resources that could improve their comfort and quality of life.

With funding from a Trinity Health Innovation Grant, Mount Carmel Health System in Columbus, Ohio, launched a pilot project in October 2015 to test the effectiveness of new program in improving the patient care experience. It was designed to enhance their ability to identify populations to increase appropriate enrollment and to determine the efficacy of newly specially-trained Community Advanced Illness Management (AIM) team.

"Patients, families, their caregivers and medical practitioners lose out on valuable services because, they don’t understand what palliative care is,  confuse it with hospice, aren't referred  or they simply don’t understand how we can help them," said Lori Yosick, Director of Community-Based Palliative Care at Mount Carmel. "So our team at Mount Carmel Palliative Care and Hospice proposed a breakthrough new way to use predicative analytics to identify an at-risk population and address unmet needs for the seriously ill living in the community."

The first step was to partner with an outside vendor, Turn-Key Health, to develop palliative care specific predictive analytics to systematically identify and reach out to a population of chronically ill patients in the community who would benefit from services. 

Next, they created a unique person-centered model based on domains of palliative care that shifted the focus of care from the hospital or ED to the home. Care was provided by telephonic and in-home support by a specialty-trained palliative care team.  Assessments and care were documented in a portal provided by the vendor and key performance metrics were embedded in patient records for quality reporting.

Participating patients had access to resources invaluable for improving comfort and the quality of life from a coordinated team approach such as RN, Advance Practice Nurse and social worker home visits.  The model even helped support the caregiver by providing education and encouragement, and validating some very hard decisions about caring for patients and communicating what the patient valued and wanted regarding the care during advanced and terminal illness.

The pilot was deployed over nine months, serving more than 200 patients identified from a target population of Medigold subscribers. Enrolled patients had complex needs, with 73 percent using eight or more medications and 86 percent aged over 80 years.

The pilot results were impressive. The interventions increased care coordination and care quality while reducing health expenditures. Patient satisfaction exceeded targets. AIM enrollees cost an average of $200 less per member per month. Patients were able to receive care at home, rather than at the hospital, 61 percent more often than patients in the control group.  The financial impact on savings and revenue was estimated at $770,000.

"We saw a positive impact in all of key pilot program metrics," said Maria Gatto, Trinity Health Director of Palliative Care, "which supports replicating this successful program in other Trinity Heath ministries." 

Replicating the AIM Care Model at other Trinity Health ministries

A replication plan is underway to scale this innovative new community-based palliative care approach beginning with the NextGen Accountable Care Organizations. Trinity Health is also working to develop the capabilities to support the data needs in-house, which reduces the expenses of the program going forward. Yosick is also facilitating office hours and design team meetings to share the resources, tools and processes for programs developing community-based palliative care.

"Each time an innovation project is replicated, it’s a win for both our organization and the communities we serve," says Anna Marie Butrie, vice president, Innovation Program and Services. "Thanks to the great work by Lori, Maria and the team with this pilot, more ministries will now have the opportunity to replicate this exciting new model." 


About Trinity Health Innovations

Trinity Health Innovations provides pathways, funding and support that enables innovative IDEAs to grow and flourish and scale across the health system. The I.D.E.A. model — Identify, Develop, Explore and Advance — spurs this work.


About Trinity Health

Trinity Health is one of the largest multi-institutional Catholic health care delivery systems in the nation, serving diverse communities that include more than 30 million people across 22 states. Trinity Health includes 93 hospitals, as well as 120 continuing care programs that include PACE, senior living facilities, and home care and hospice services. Its continuing care programs provide nearly 2.5 million visits annually. Based in Livonia, Mich., and with annual operating revenues of $16.3 billion and assets of $23.4 billion, the organization returns almost $1 billion to its communities annually in the form of charity care and other community benefit programs. Trinity Health employs about 131,000 colleagues, including 5,300 employed physicians. Committed to those who are poor and underserved in its communities, Trinity Health is known for its focus on the country's aging population. As a single, unified ministry, the organization is the innovator of Senior Emergency Departments, the largest not-for-profit provider of home health care services — ranked by number of visits — in the nation, as well as the nation’s leading provider of PACE (Program of All Inclusive Care for the Elderly) based on the number of available programs. For more information, visit You can also follow @TrinityHealthMI on Twitter.