For more than 200 chronically ill patients in the San Fernando and Santa Clarita valleys, doctors make house calls. This specialized program has resulted in significantly fewer emergency department visits and extended hospital stays.

Most importantly, Facey Medical Group’s palliative care program has increased patients’ satisfaction with their medical care and helped improve their quality of life. Palliative care helps patients manage symptoms to alleviate the need for acute care.

“It’s quite simply the right thing to do. People facing health challenges most often are much happier at home, and we wanted to do our part to make that possible,” said Fredrick Russo, M.D., who recently retired as Facey’s president and CEO. Dr. Russo is credited with championing the plan.

A case study of the program and its results was published recently by Duke University’s Margolis Center for Health Policy.

This community-based service provides home visits, after-hour access, education, regular check-ins by phone, social work and chaplaincy support as requested. It was introduced in 2016 in partnership with Providence TrinityCare, a provider of hospice and palliative care. Facey is an affiliate of TrinityCare’s parent organization, Providence St. Joseph Health.

The care team works with patients and their families on goals of care to improve quality of life. Most of these patients suffer from degenerative chronic illness such as heart failure, chronic obstructive pulmonary disease, dementia disorders including Alzheimer’s disease or diabetes, with serious complications. Most are not in need of hospice care at this point but, through the program, have documented their plans for future health care.

Facey identifies patients with serious diagnoses and recent hospital care for the program. Additionally, TrinityCare takes referrals from community physicians and Providence hospitals.

A review of 2017 data show a 70% reduction in hospital admissions and a 55% decrease in emergency department visits. 2018 data were not as remarkable but nonetheless significant. Among the key components of this success are a multidisciplinary team and 24-hour access to help patients manage their symptoms. Sharing an electronic health care record allows for a high level of coordination of care among primary care providers, patients and the palliative care team.

Facey has been innovative in providing the initial and ongoing funding for the team, which has expanded to a physician, two nurse practitioners, three registered nurses, three social workers and a chaplain. Shortly before partnering, TrinityCare had received a grant from the UniHealth Foundation to expand palliative care in the Valley.