TIER-PALLIATIVE CARE: A population-based care delivery model to match evolving patient needs and palliative care services for community-based patients with heart failure or cancer

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ABSTRACT Persons with serious illness suffer from poor symptom control, decreased quality of life (QoL) and poor communication with their healthcare providers, especially in terms of goals of care discussions (GOCD). Palliative care, when offered alongside disease management, offers improved symptom control, QoL, communication, caregiver satisfaction and reduced caregiver anxiety. Due to a limited specialty-trained palliative care workforce, however, patients and their caregivers often cannot access these benefits, especially in the community. These needs are particularly acute in advanced cancer and HF, the two leading causes of death in the US which also model the most common illness trajectories. The dynamic nature of these illnesses presents distinct symptom patterns and changing functional status that require an adaptive, dynamic model of palliative care delivery. Yet, workforce shortages prevent scaling of existing community-based specialty palliative care models. To meet patient/caregiver dyads' needs with a limited workforce, new models that deploy palliative care clinicians based on patient's illness trajectory and changing needs are required. The innovative TIER-PALLIATIVE CARE (TIER-PC) model provides the right level of care to the right patients at the right time. TIER-PC increases the number and intensity of specialty trained palliative care disciplines added to the dyad's care team as their symptoms worsen and function declines. In Tier 1, patients who can care for themselves and have easily managed symptoms, receive support from a community health worker (CHW) trained to elicit illness understanding in a culturally competent way. In Tier 2, for patients with poorer function and mild symptoms, a social worker (SW), trained in serious illness communication, joins the CHW to further elicit patients' illness understanding and goals, and provide caregiver support. In Tier 3, as function decreases and symptoms increase, an advance practice nurse (APN) joins the CHW+SW to manage complex symptoms. In Tier 4, for those patients with the poorest function and worst symptoms, an MD joins to address the most complex needs (e.g., end-of-life treatment preferences and multifaceted symptom control). The CHW follows dyads longitudinally across all tiers and re-allocates them to the appropriate tier based on their evolving needs. We will evaluate TIER-PC's efficacy in a multi-site, single blinded, two arm, randomized controlled trial. Patients with advanced cancer or HF will receive regular assessments by the TIER-PC team to: address symptom and psychosocial needs; improve illness/prognostic understanding; prescribe medications; and address goals of care. We will enroll and randomize 400 patients with HF or cancer and their family caregivers to receive TIER- PC or an augmented control. We will follow dyads for 12 months to determine if TIER-PC: improves patients' symptom control and QoL (primary outcomes), patient-reported GOCDs and caregiver satisfaction; reduces caregiver anxiety and post-traumatic stress; and decreases patients' healthcare utilization and cost. By matching demand to the scarce workforce, our scalable model can improve care for patients with cancer or HF.