Palliative Care: Connecting Care for the Most Vulnerable

Caring for a patient who is dealt a life-threatening diagnosis, serious illness, or complex condition can bring out the very best in doctors, nurses, and other healthcare professionals. It's what they train for and where they shine. It's the same for us at Aspire Health.

Our palliative care support is designed to augment either a primary or specialty care provider's treatment with needed planning during a serious illness. Nurse practitioners, both in the patient's home and virtually, can provide needed palliative care services, outreach, and coordination that can improve the patient's well-being — from advanced care planning to pain management to coordination with their caregivers.

Access to our palliative care services can improve health outcomes, keep patients from developing complications like depression, and can help avoid unnecessary, aggressive, and costly care. We deliver that support while keeping patients' dignity and decision-making foremost in mind.

Our Approach

Aspire Health connects primary and specialty care providers and their patients with a uniquely personalized, integrated palliative care model. By meeting people in the comfort and safety of their homes, we strive to optimize whole health for those with the greatest need and bring real comfort to patients and caregivers' lives.

As the world's largest community-based provider of at-home palliative care services, with a presence across the 48 contiguous states,1 Aspire Health is working toward those goals in partnership with primary care providers and other medical specialists. Our unique approach to personalization and integration — made possible by an interdisciplinary team — gives time back to overscheduled and busy care providers.

Each patient's team includes a palliative care physician, advanced practice provider, registered nurse, and social worker. Accessible to patients and caregivers around the clock, the team collaborates with patients' primary care provider to address individual medical and psychosocial needs.

Advanced Practice Provider

  • Nurse practitioner or physician assistant, on call 24/7
  • Conducts initial and follow-up visits, and advance care planning
  • Develops care plan
  • Prescribes medication, writes clinical orders

Registered Nurse

  • Provides support by phone and status checks
  • Triages incoming clinical issues
  • Aids in hospitalization prevention
  • Connects patient with home health and long-term support services
  • Facilitates hospice transitions

Palliative Care Physician

  • Leads outreach and education
  • Oversees team
  • Coordinates care with patient's physicians
  • On call 24/7

Social Worker

  • Provides psychosocial support
  • Addresses factors influencing social drivers of health
  • Aids in advanced care planning and goals of care discussions
  • Provides hospital and hospice planning

When we work together as care provider and palliative care teams, we can look to claims data and clinical records to identify patients at risk for adverse events, then confirm with a face-to-face evaluation. Together, we can proactively manage symptoms and help keep patients well and empowered. We start with a collaborative care plan, created in partnership with patients and designed to address their medical, behavioral, and social needs.

Connected Palliative Care Outcomes

When we partner with care providers to connect them to our integrated palliative care model, things start to change, for the better.

For example, on average, patients who receive palliative care support have fewer hospitalizations than those in other care models.2 Fewer hospitalizations means lower chance for complications and hospital-acquired illness or infection; it means more time at home without significant pain or complications; and it means fewer acute and emergency visits that physicians need to manage.

Patients who receive support from Aspire Health also participate in advance care planning at higher rates than the national Agency for Healthcare Research and Quality (AHRQ) benchmarks.3 It means more people facing serious or chronic illness can feel secure knowing that their family and care providers all understand what to expect in case of complications or disease progression. It means patients have shared their wishes with the people around them before it becomes difficult or impossible to communicate with them. It also means peace of mind — not only for patients and their families and caregivers, but also for physicians, hospitals, and health systems.

Advance Care Planning: Aspire Health Program vs. National Benchmark

Advance care plan POLST completed: Aspire Health: 81%, AHRQ benchmark: 50%

Recent advance care plan discussion: Aspire Health: 97%, AHRQ benchmark: 12%

Indicators like fewer hospitalizations and advance care planning not only are signs of better outcomes but of avoided unnecessary costs. Aspire Health has been able to deliver savings of $600 to $900 per member, per year for Medicare consumers and $500 to $800 per member, per year for Medicaid consumers through reduced hospitalizations alone, driving affordability for consumers, employers, and taxpayers.3

Admissions Per Thousand: Aspire Health Program vs. Non-Aspire Health Program

Non-Aspire Health patients last 9 months of life.*: 3,196

Non-Aspire Health patients last 12 months of life.*: 2,524

Aspire Health patients: 1,057

* Patients who met Aspire Health enrollment criteria but did not enroll.

Forward Together

Since 2013, Aspire Health has had the privilege of providing palliative care to nearly 200,000 patients facing serious illnesses.3

In the coming years, we will continue to support patients and their primary care providers — with a collaborative, coordinated approach that honors each patient's humanity, dignity, and whole health.

1 Aspire Health (2022). 2 Frist, W.H. MD; Presley, M.K. MD, JD. Training the Next Generation of Doctors in Palliative Care Is the Key to the New Era of Value-Based Care. Academic Medicine 90(3):p 268-271, March 2015. | DOI: 10.1097/ACM.0000000000000625 3 Internal report (October 2022).