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We can bring powerful data and care pathways. We can co-invest in resources, whether they’re nurses, care managers, socialworkers. We also can help them create risk sharing contracts with palliativecare organizations. But as agilon, we don’t provide the care ourselves.
I saw a person who couldn’t access the social determinants of health. And yet in my other rotations and experiences, it was so clear that we were resourcing people with palliativecareresources very well. We just hired a nurse. The Peach program has cared for over 1,000 clients.
I’m a health policy consultant for national palliativecare organizations and often advocate for advance care planning, a process that helps people with serious illness prepare for future decision-making. I recently saw a patient whose case typifies how advance care planning and policies to support it can work.
A colleague of mine up in Toronto did an ICU study actually asking clinicians, nurses, docs, six-month prognosis, both functional and vital status and compared it with actual observed status. We have our socialworkers and our psychologists and we know how to manage these symptoms. Were these two resources already there?
More recently Sharon Kaufman ‘s book And a Time to Die described the ways in which physicians, nurses, hospital systems, and payment mechanisms influenced the hour and manner of patient’s deaths. Eric and I are joined today on this podcast by Anne Kelly palliativecaresocialworker to discuss these issues with Liz.
So, basically, with a stepped care model, the goal is to tailor care delivery to the patient’s needs while at the same time utilizing less clinician resources. How it works is that all patients will have access or encounters with the specialty trained clinician, a psychologist, a socialworker, a palliativecare clinician.
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