Provider: Facey Medical Group
Background: Facey Medical Group, a large multispecialty practice in Southern California, identified a group of patients whose needs could not be met by traditional clinic visits. In short, there were patients with advanced chronic illness or serious diagnoses whose conditions were not well controlled, leading to significant hospitalizations and emergency department (ED) visits, but these patients did not yet need comprehensive hospice services. To improve these patients’ function and experience, Facey launched a community-based palliative care program that provided home visits, after-hours access, education, regular telephonic check-ins, social work, and chaplaincy support.
The program has started to show reductions in unnecessary hospitalizations and ED visits while improving patient satisfaction. This was implemented in the context of a number of shared- and full- risk contracts with commercial payers, including a commercial ACO contract focusing on community-based palliative care, which provided financial flexibility for a high-touch care approach and services not traditionally supported by fee-for-service payment.