The Reaching Out to Enhance the Health of Adults in Their Communities and Homes (REACH) program helped seriously ill, elderly patients reduce hospital visits.

• The program included patients with diabetes, chronic obstructive pulmonary disease, and congestive heart failure.

• The goal was to help patients become medically stable and keep them out of the hospital.

• REACH evolved into a palliative care program with similar goals.

A healthcare provider’s case management-style program produced a 43% reduction in hospital visits and a 24% reduction in ED visits within an 18-month period, according to authors of a new study.1

The program, Reaching Out to Enhance the Health of Adults in Their Communities and Homes (REACH), involved a care model that integrated palliative care with primary care for seriously ill, elderly patients.

This case management model can be an alternative to the traditional trajectory of seriously ill, older patients moving from inpatient hospitalization into long-term care, says Timothy P. Daaleman, DO, MPH, professor of family medicine at the University of North Carolina (UNC) at Chapel Hill. Daaleman also is a professor in the department of social medicine and a research fellow at the Cecil G. Sheps Center for Health Services Research.

Patients with diabetes, chronic obstructive pulmonary disease, and congestive heart failure are good matches with the program as they are the same patients who frequently use hospital services, says Robin Motley, MSN, FNP, a home-based palliative care nurse practitioner at UNC Palliative Care at Home.

“Our goal was to see if we could prevent their chronic illnesses from getting out of control and landing them in the hospital if we visited them every three months at home,” Motley says. “With REACH, we were doing primary care in the home.”

Until population health and value-based care models received demonstration project funding through the Affordable Care Act (ACA), healthcare organizations did not attempt programs like REACH because they were not cost-effective, Daaleman says.

“A decade ago, it was too costly to have physicians visit patients. It would not generate enough income to sustain the program,” he says.

When ACA demonstration project funding became available, alternative models were financially feasible.

The program’s funding source changed, and the program changed from REACH to a palliative home care model with the same goals of providing patients with in-home symptom management and disease management to prevent readmissions, Motley explains. (See story in this issue on how the home-based palliative care program works.)

“We really try to get ahead on the process that can quickly spiral out of control and land people in the emergency room,” she adds.

The program’s team includes two nurse practitioners, two physicians, two registered nurses, and one social worker, Motley says.

The palliative care model is a natural fit for a home-based primary care program.

“We developed a home-based primary care hybrid of two different models,” Daaleman says. “One was home-based primary care, and the other was home-based palliative care.”

The challenge was coordinating patients within those two models and serving both populations.

“We built infrastructure in the electronic medical record and came up with ways to communicate across different providers,” Daaleman says. “We had a nurse manager [and] social worker, and had the physician go out to do assessments.”

Case managers helped handle communication, manage caseloads, and assess patients’ care needs based on comorbidities and the seriousness of their illness.

The program hired two nurse practitioners and one part-time physician, but finding people with the right skill sets was a challenge, Daaleman notes.

“To work with this population was fairly unique,” he explains. “You needed people with clinical skills and who could help patients manage what was going on in their homes.”

The necessary skills include being unafraid of handling complex patients with messy situations and being creative in finding solutions. Also, the individual needs to be a team player.

For example, a patient could be clinically unstable but unwilling to go to the hospital. For many providers, the easiest course of action would be to call 911 and have the patient transported to the hospital. But the program encouraged providers to manage patients in their home environment, Daaleman says.

“These are people who have chronic, serious illness, and having an extra layer of support in the home would be beneficial in managing their symptoms,” Motley says.

“Many times, it is difficult for people with serious illnesses to leave their homes.”

For instance, an elderly patient with dementia might become disturbed when visiting new places. Breaking out of this patient’s daily routine could be disruptive, she says.

“We don’t see the people who are healthy and able to get out to their doctor’s appointments. We don’t do this as a convenience,” Motley says.

The population Daaleman and co-investigators studied was particularly fragile. Of the 159 people enrolled, 50 died while in the program, he says.

“A number of these patients were dying at home,” he adds.

Since the demonstration project ended, the program has continued as a home-based palliative care program. “The infrastructure is all the same, and we haven’t had much staff turnover,” Daaleman says.

“It’s a fairly flexible program where we’re trying to find the sweet spot between home-based primary care and home-based palliative care,” he adds. “There’s a little space in between, consisting of patients who are probably on that trajectory for palliative care, but they or their caregivers are not ready for it.”

One patient with dementia was in the program for six months before the patient and his wife started to talk about advance care planning, laying the foundation for accepting palliative care, Daaleman says.

“Technically, the patient is not eligible for hospice, but he has progressive, terminal disease — dementia,” he explains. “We were concerned about his functional status and comorbidities.”

It helped the couple to have providers visit them at home and to have people the patient and caregiver trusted introduce the concept of palliative care. One of the program’s key features is having the team start advance care planning conversations with patients and their families, Daaleman says.

It might take three or more visits before the patient is ready to hear about advance care planning, palliative care, or hospice, largely because of the stigma associated with hospice and palliative care, he notes.

“We provide a continuum of care for patients, between primary care and palliative care,” Daaleman says. “This can take months or years, preparing patients and coming up with a serious primary care approach.”


1. Daaleman TP, Ernecoff NC, Kistler CE, et al. The impact of a community-based serious illness care program on healthcare utilization and patient care experience. J Am Geriatr Soc. 2019;27:Epub ahead of print.