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

New Palliative Care Pilot Programs – May 29, 2018

We recently launched our Community-based Palliative Care Pilot Programs! These pilots will be critical in operationalizing palliative care programs in the community, and will help our PCMH partners to directly reduce avoidable hospital admissions and improve the quality of the patient’s life. The strategic alignment of palliative care programs with the needs of high-utilizers has been growing in recognition. This alignment has seen: a Decrease in Mortality Rates, a Reduction of Hospital Admissions, a Reduction of Readmissions, a Reduction in ICU Days, a Reduction in claims cost PMPM.

The Power of Palliative Care – What can this Meaningful Service do for your Patients – November 22, 2017

In celebration of National Hospice month during the month of November, Care Compass Network (CCN) would like to help explain the difference between Hospice Care and Palliative Care. These two services are often confused with each other, but are equally […] Read More

Important Notice – Quarterly Reporting due by October 25th – October 18, 2017

For Partners Contracted to do Project Work: With the first 6 months of DSRIP Year 3 complete, CCN must submit the patient engagement reporting data to the DSRIP Independent Assessor in order to earn performance dollars tied to speed and scale. If you have not submitted your date for April 1st – September 30th 2017, please submit your activity by October 25th. All speed and scale reports or any document (could include a screenshot, email, word document, excel file, etc) that includes PHI should be submitted via the sFTP site. For additional information on the sFTP site, please click here to view the CCN sFTP Guide.

Care Compass Network Will be Submitting Baseline Numbers for Metrics Associated with the Palliative Care Project by October 2017 – September 15, 2017

Care Compass Network (CCN) will be submitting baseline numbers for five metrics associated with the Palliative Care project which use the results of the Integrated Palliative Outcome Scale surveys (IPOS). In order to earn approximately $1 million, CCN needs to report the numbers related to the IPOS forms completed between 1/1/17 – 6/30/17.

Care Compass Network Supports Partner Organizations Through IT Funding Opportunities – August 24, 2017

Care Compass Network (CCN) can help support partner organizations through approved IT funding opportunities. Currently, programs are in place to assist partners with new implementations of EMR/ EHR systems and to provide funding to accommodate […] Read More

Palliative Care (Project 3gi) Webinar – August 8, 2017

Stephanie Woolever, Care Compass Network Project Manager, and Rachel Francis, Population Health Analyst, discuss the quality metrics for project 3gi – Palliative Care. Stephanie provides an overview of Palliative Care & cover project-specific changes […] Watch Now

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.