Integration of Palliative Care in PCMH Primary Care Offices – Project 3.g.i


Palliative Care is enhanced medical care for people with serious illness, focusing on providing patients with relief of symptoms, pain, and stress – whatever the diagnosis. To help improve quality of life for both the patient and their family, Palliative Care is provided by a team of nurses, doctors, other specialists, community and spiritual supports, where appropriate, that work together with the patient’s care team providing an extra layer of support.

Care Compass Network’s Goals

  • Increase understanding and adherence to section 2997-c The Palliative Care Information Act and section 2997-d the Palliative Care Access Act.
  • Building strong community support groups to deliver enhanced care to members while allowing physicians to work to top of licensure with a well-established interdisciplinary team.
  • Reduce avoidable hospital utilization and reduce health care costs.
  • Appropriate and complete use of DOH-5003 Medical Orders for Life-Sustaining Treatment (MOLST) as well as increased understanding and general discussions around advance care planning.
  • Qualitative data collection showing the overall value of enhanced Palliative Care Programs.

Who is Eligible to Participate in the Project?

Any Hospice organization or Primary Care Practice that is Patient Centered Medical Home (PCMH) Certified or is in the process of becoming certified that treats Medicaid members, from birth through end of life with chronic worsening health conditions.

Latest News & Updates

What is Palliative Care? – May 26, 2017

Too often when people hear the words Palliative Care, they immediately assume they are going to begin a conversation about end of life comfort care. Part of this is true but it’s not the most accurate picture […] Read More


IPOS Forms Now Available – March 16, 2017

Integrated Palliative Outcome Scale (IPOS) forms are now available on Share Point and in the Project Tool Kit. There are 3 forms: 1. the patient version for the member or a care team member to complete, 2. the staff version for members of the care team to use for assessment when a member is incapacitated, and 3. the Dementia version for use in an institutional setting for members with advanced dementia and/or Alzheimer’s. A training guide and quick reference sheet is also available to help guide the care team member through completion and use of the assessment with quick links to useful trainings and resources for a deeper understanding of specific content.