Making Community-Based Palliative Care Eligibility Determinations: Palliative Care Team Member Perspectives on Access to Information and Algorithm Use

Background: Seriously ill older adults have high risk of mortality, symptom burden, and compromised functional status, and may benefit from community-based palliative care (“palliative care”). However, identifying potentially eligible individuals is challenging. Objectives: Identify how a palliative care team makes eligibility determinations, including the use of a mortality risk algorithm. Design: Semi-structured focus groups were conducted with palliative care providers to understand how health information is used to assess Medicare Advantage plan patients’ eligibility for palliative care. Transcripts were analyzed to identify categories related to how participants used health information in making eligibility determinations. Setting/participants: All outreach and care management team members and nurse practitioners (n = 7) working for a palliative care program at a not-for-profit health care agency. Results: The palliative care team used information on symptoms, diagnoses, and acute care utilization when making eligibility determinations. The algorithm generated lists of potentially eligible patients but was deemed not useful because it provided limited information about current health status and was not well integrated into existing health record systems. Participants would like information to be current, detailed, and presented in one location. Conclusions: Palliative care team members used a variety of indicators of unmet care needs to make eligibility determinations. A mortality risk algorithm to identify potentially eligible patients was insufficiently detailed to be useful in final eligibility determinations. These findings provide insights into how health data can be presented to better integrate health information from mortality risk algorithms into existing workflows to support palliative care eligibility decision making.