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Title: Prospective outreach for palliative care: the One Front Door pilot at Sutter Health and its use of electronic patient identification for proactive palliative care referral

Authors: Sylvia Sudat 1
Sangeeta Joshi 2
Bernadette McSwain 2
Elizabeth Mahler 3
Praba Koomson 2
Sharyl Kooyer 2
Kathy Blanton 3

1 Center for Health Systems Research-East, Research, Development & Dissemination, Sutter Health
2 Advanced Illness Management, Sutter Population Health Services
3 Clinical Integration, Office of Patient Experience, Sutter Health

Background/Objective/Research Question:
Prospective identification of palliative-care-eligible patients from electronic health record (EHR) data is promising, but can be difficult to implement into clinical practice. We describe the use of electronic patient identification to drive prospective provider engagement in Sutter Health’s (SH) One Front Door pilot.

Methods/Study Design:
SH is a large health system in Northern California serving approximately 3 million patients. In 2018, Sutter Health validated and operationalized an EHR-based palliative care (PC) eligibility algorithm, which produces daily a registry of PC-eligibility scores for all adult patients. One Front Door, a SH pilot program providing a single point of access to SH’s multiple palliative care programs, prospectively engages providers and uses the PC registry for proactive referral.

From November 2018-January 2020, 980 electronically-identified patients were reviewed for potential PC referral. Of these, 500 (51%) were found to be not yet appropriate based on PC program-specific prognosis guidelines, 98 (10%) were already receiving PC services, and 45 (5%) were deceased. Of the remaining 337, 118 (35%) were successfully enrolled in a PC program based on proactive referral. The major reason for non-enrollment was physician/patient refusal (109, 32%). The number of refusals declined over the course of the pilot to-date, and the receptiveness of physicians to receiving proactive referrals improved. The number of participating physicians grew from 40 to 75.

The use of our PC identification algorithm, combined with clinician review and proactive physician engagement, has been a successful tool in referring and enrolling patients in SH PC programs.