The Impact of a Community-Based Serious Illness Care Program on Healthcare Utilization and Patient Care Experience

Timothy P. Daaleman
Natalie C. Ernecoff
Christine E. Kistler
Alfred Reid
David Reed
Laura C. Hanson
Peer-Reviewed Article
February 2019


Care model that integrates home-based primary care and palliative care for patients with serious illness reports reduced health care utilization and improved patient care experience.  


Patients with serious illness have many complex health care needs and are at high risk of care fragmentation. The University of North Carolina designed the Reaching Out to Enhance the Health of Adults in Their Communities and Homes (REACH) program to reduce this care misalignment by integrating primary and palliative care services into one program. The REACH program uses an interdisciplinary team, led by a nurse care coordinator, to develop a comprehensive care plan that incorporates symptom management and advanced care planning for all participants. This article describes the care model and evaluates the impact of the REACH program on health care utilization and patient care experience.


Patients enrolled in the REACH program had 43 percent fewer hospital visits and a 25 percent reduction in emergency department (ED) visits as compared to patients who were receiving usual care. A patient survey conducted via telephone highlighted positive patient-reported experiences around care quality, delivery, and communication with REACH providers.


Health care providers can use the REACH model as an example of how combining home-based palliative care and primary care into one singular intervention to treat patients with serious and chronic illness can help reduce hospital and ED visits while maintaining high patient satisfaction.

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