Serious Illness

We understand serious illness to mean any health condition with poor survival outcomes that makes daily life difficult for a patient and/or their caregiver.

Serious illness care has long been an area in need of improved care and reformed payment models. As end-of-life costs escalate, both North Carolina and South Carolina routinely fall behind the nation and neighboring states on measures indicating how patient choice and quality of life are prioritized.

Care that focuses on eliciting patient needs reveals a preference for care at home among the seriously ill, however, both Carolinas rank below the state average for the share of Medicaid long-term supportive services expenditures in a home or in a community-based setting.

Providers and case managers have little latitude to activate flexible, goal-concordant care options for patients and caregivers based on patient input. Payors have few choices when it comes to reimbursing for expensive treatment interventions that patients potentially don’t want or need to enhance their quality of life but are intended as measures to help yet have even fewer options to support alternative assistance measures that may be more meaningful. Outcomes for both patients and caregivers can be costly and painful in the name of prolonging a fragile life but often go against a patient’s wishes or best interests, ultimately.

Currently, there is no comprehensive payment model that allows a care manager to select interventions appropriately and compassionately from a variety of services to support a patient who is approaching the end of life. Care that is driven by traditional fee-for-service models often leads to avoidable or excessive treatments that don’t accomplish patient goals and affect not just the individual, but family and caregivers, as well. Payors and providers need more flexibility to help identify and provide innovative interventions to patients and caregivers for better outcomes and satisfaction at the most important time.

To reach a future in serious illness care where we can measure improved outcomes for patients and caregivers, lower costs for families and payors, and reduce disparities in access, will require a complex approach.

CaroNova adheres to a rigorous 7-step process to identify and guide solution development. Through the earlier discovery stages of this process, we determined that to address the challenges truly and systemically around serious illness care we cannot rely on one program model or one policy change but will build a portfolio of potential solutions that can provide evidence-based serious illness care to 100% of patients who meet a pre-determined clinical criterion. This suite of interventions should involve both upstream strategies like provider training, and immediate clinical care solutions.

Solutions should focus on developing new payment strategies that support coordination across a continuum of care for goal-concordant services to patients and caregivers, and advocate for policy opportunities that eliminate barriers to this care.