Palliative Care Integration into Primary Care

Project 3.g.i. Integration of Palliative Care into Patient-Centered Medical Home Model.

Alliance staff contact: Carol Ann Tiberia | 518.701.2282

Objective: Increase access to palliative care programs in Patient-Centered Medical Homes (PCMHs).

Project Description:  Per the Center to Advance Palliative care: “Palliative care is specialized medical care for people with serious illnesses. It is focused on providing patients with relief from symptoms, pain, and stress of a serious illness—whatever the diagnosis. The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work together with a patient’s other doctors to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment” ( Increasing access to palliative care programs for persons with serious illnesses and those at end-of-life can help ensure care and end-of-life planning needs are understood, addressed and met prior to decisions to seek further aggressive care or enter hospice. This can assist with ensuring pain and other comfort issues are managed and further health changes can be planned for.

Definition of Engaged Patients: The number of participating patients receiving palliative care procedures at participating sites, as determined by the adopted clinical guidelines.

Project Requirements:

  • Integrate Palliative Care into appropriate participating primary care providers who have, or will have, achieved NCQA PCMH and/or APCM certification.
  • Develop partnerships with community and provider resources including Hospice to bring the palliative care supports and services into the practice.
  • Develop and adopt clinical guidelines agreed to by all partners including services and eligibility.
  • Engage staff in trainings to increase role- appropriate competence in palliative care skills and protocols developed by the PPS.
  • Engage with Medicaid Managed Care to address coverage of services.
  • Use electronic health records (EHRs) or other IT platforms to track all patients engaged in this project.