Serious Illness Approaches by ACOs: Facey Medical Group

Robert Saunders
William Bleser
Case Example
May 2019


This case study analyzes a successful example of a medical group partnering with a home health agency to provide community-based palliative care for high-risk members of their accountable care organization (ACO).


Facey Medical Group, a physician-owned medical practice in southern California, operates an ACO with multiple commercial shared and full risk contracts. Significant hospitalizations and emergency department (ED) visits by patients with advanced chronic illness or serious diagnoses led Facey to create a community-based palliative care program to better manage their conditions. To implement this program, Facey partnered with TrinityCare, a hospice and palliative care home health provider. TrinityCare provided an interdisciplinary team of palliative care providers with Facey primary care physicians serving as the attending physicians for patient medical care.

This case study explores Facey’s palliative care approach, patient identification methodology, factors necessary for their partnership with TrinityCare, implementation challenges, and implications for scaling the program.


Patients receiving care from TrinityCare had a 70 percent reduction in hospital admission and a 55 percent reduction in ED visits. Patient and family satisfaction surveys conducted within the program’s first year found high patient satisfaction with quality, experience, and symptom management. Finally, all patients who went through the program had documented emergency and end-of-life care goals.

Internal analyses of Facey’s organizational competencies revealed that working with a partner organization to implement a community-based palliative care program depended on strong communication and relationship building between organizations, a well-developed strategy to identify the target patient population, and shared access to the same electronic medical record. 


Facey’s experience in implementing their community-based palliative care program through a partnership with TrinityCare may help ACOs and other health organizations develop and implement similar partnerships when managing their populations with serious illness.

Posted to The Playbook on