Chronic disease affects more than 120 million people across the United States and is the leading cause of death and disability1. These patients often pursue palliative care to restore comfort and improve their quality of life during their final phase of life2. Within the last five years, institutions have begun discussions regarding palliative care, but there has yet to be a change in the trajectory of care. It is common knowledge that the cost of end-of-life care is astronomical, increasing the patient’s burden rather than meeting their needs. A Palliative Care Medical Home should support people through the disease process, provide anticipatory guidance, and help them define their vision for the future.

In contrast to Expert Medical Opinion, which is an episodic interaction, the aim of Palliative Care Medical Home is to support the member and their family through chronic disease, whether newly diagnosed or present for some time. When you are dealing with a chronic health issue, it is not uncommon to be overwhelmed by common, day-to-day affairs. Daily needs such as cooking meals and refilling prescriptions are difficult activities in the face of chronic disease. With the guidance of the Physician Case Manager, members can find solutions to these acute concerns and identify local resources to help meet their needs, allowing them to focus on the chronic issues.

It is often difficult for patients to have these conversations with their current treating physicians. They think it means they will no longer be treated or their physician has given up on them. Many are even afraid that they will die. Through an independent party like Advance Medical, they are able to have these difficult discussions, receive anticipatory guidance, and develop an actionable plan in support to ensure their conditions are successfully managed.

When members consult Advance Medical regarding palliative care, they discuss their diagnosis and symptoms with a designated Physician Case Manager. To commence the process, their primary medical records are compiled in order to assure that the patient and the physician’s understandings of the condition are aligned. It is not common that there is some misunderstanding between the patient and physician. The misinterpretations are further amplified when each clinical visit is only 5 to 7 minutes in duration. The Physician Case Manager can work to correct this by coordinating with the treating physicians to insure the patient’s vision is accurately understood by those involved. Being the liaison between the patient and the treating physicians is essential in ensuring the patient’s goals and objectives are properly relayed.

Advance Medical also has a team of psychiatrists dedicated to having discussions and developing support systems to combat depression and other behavioral health issues as they arise. Patients also receive consultation to aid in effectively communicating their wishes and desires with their family members in the face of such trying times.

The sole objective of palliative care is to help patients be comfortable throughout the disease course. It is important for the patient to understand that palliative care does not equal hospice care. Palliative care’s aim is to determine the patient’s goals and objectives in regard to their care and life. The best way to achieve this is to have programmatic check-ins with the physician to find out how they are feeling and what needs to be acutely managed. Furthermore, it is important to highlight their ambitions, whether they desire to be out of the hospital for three weeks, they wish to spend time with their grandchildren, or they want to live their life with as little pain as possible. Palliative care can guide the patient in achieving such desires. Only through a developed relationship with a Physician Case Manager can this longitudinal identification and advocacy process be attained.

Identifying their ideal life is paramount to improving the patient’s quality of life. Palliative care is dedicated to managing pain and improving the standard of health and comfort. Programmatic questioning is a method to monitor the patient’s vision and help them meet their targets. Some of the attainable objectives are (1) scheduling appointments with their treating physician to talk about palliative care, (2) educating the patient in ways to convey their wishes for palliative care to their family members, (3) discussing the meaning and objectives of healthcare proxy and how to obtain one, and (4) changing the culture of healthcare to include palliative care and all necessary discussions.

We strive to help our client’s support their members with chronic disease. This can decrease absenteeism and, more importantly, improve the quality of life and health of the individual. It is Advance Medical’s ambition is to enhance the outreach of palliative care, ensuring that our members’ needs are met to their fullest potential.

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