Headline

This resource guide describes the core elements and evidence base behind a home- and community-based palliative care model that was designed by stakeholders to support the health needs of people with serious illness.

Context

People with serious illnesses often experience acute events, seek crisis care, or choose institutional care for treatment because they have difficulty managing their health conditions at home. This resource, which describes the core elements of the Arizona Coalition Model, can help stakeholders seeking to implement a home- and community-based palliative care program focused on helping people with serious illness to remain living in their homes. The Arizona Coalition Model, conceived by 40+ stakeholders across the state, was informed by a best practices study that evaluated how evidence-based community services and support could have the greatest impact on supporting people with serious illnesses.

About this Tool

This resource guide was designed with the flexibility to be implemented by a variety of organizations and supported by a variety of payment models. It includes:

• Guidelines and supporting evidence to identify target populations with serious illness and unmet needs
• Descriptions of program services, such as those connected to assessment, symptom management, education, psychosocial support, and social determinants of health 
• Operational requirements related to staffing, partnerships with other providers and organizations, polices, and workflows
• Measurement strategies to determine success, such as days at home, acute crisis utilization, and outcomes equity

Takeaways

Although this model was designed by Arizona stakeholders, complex care program decisionmakers across the nation can use this guide to inform efforts to support the health and social needs of patients with serious illnesses.