A care model that integrates home-based primary care and palliative care reduced health care utilization and improved care experience among patients with serious illness.   

Background

Patients with serious illness have complex needs and are at high risk of fragmented care. The University of North Carolina designed the Reaching Out to Enhance the Health of Adults in Their Communities and Homes (REACH) program to reduce care misalignment by integrating primary and palliative care services into one program. The REACH program uses an interdisciplinary team, led by a nurse care coordinator, to develop a comprehensive care plan that incorporates symptom management and advanced care planning for all participants. This article describes the care model and evaluates the impact of the REACH program on health care utilization and patient care experience.

Findings

Patients enrolled in the REACH program had 43% fewer hospitalizations and a 25% reduction in emergency department (ED) visits, compared to patients receiving usual care. A patient survey conducted over the phone highlighted positive patient-reported experiences around care quality, delivery, and communication with REACH providers.

Program/Policy Takeaways

Health care providers can use the REACH model as an example of how combining home-based palliative care and primary care into one intervention to treat patients with serious and chronic illness can help reduce hospital and ED visits while maintaining high patient satisfaction. Although based in a suburban region, REACH’s service area includes rural census tracts, making it a valuable model for extending care to rural older adults with serious illness.