Meet the Top 25

CAPC is excited to announce the Top 25—finalists in the second John A. Hartford Foundation Tipping Point Challenge.

Winners will be announced in October 2021.

Top 25 Finalists

  • Ascension

    “Addressing Social Determinants of Health through Screening and Resource Referrals”

    Serious illness outcomes reflect pre-existing racial and ethnic disparities in health care access and quality in our communities. Minority populations are more likely to receive unhelpful aggressive care at end of life, including transitions, and less likely to complete advance directives and enroll in hospice. The factors that contribute to these disparities are complex, and include health system issues, care provider and policy considerations, and cultural issues.

    Social determinants of health (SDOH) are closely linked to health outcomes among populations historically exposed to health care disparities, and present actionable targets for enterprises committed to improving care for all people living with serious illness. The Ascension team plans to address SDOH barriers and needs of community members through the implementation of a systematic SDOH screening and resource referral process.

    Ascension - Tipping Point Challenge Top 25 photo

  • Bluegrass Care Navigators

    “Creating Access to Palliative Care Across Settings”

    The US health care system is maladaptive in meeting the needs of patients with seriously illness. Moreover, there are limitations to the Medicare hospice benefit that limit the ability of this patient population to receive health care that is concordant with their goals, preferences, and values.

    Recognizing the unmet needs of the people living with serious illness in our communities, Bluegrass Care Navigators (BCN) has assiduously worked to create access to specialist-level palliative care. Creating this access is dependent on community partnerships and taking on financial risk. The clinical model and financing of their specialist-level palliative care programs varies based on setting. While BCN’s partnerships with hospitals have been a model to replicate for other communities, newer initiatives focus on community-based palliative care. In the past three years, BCN has expanded their community-based palliative care program to include home-based palliative care, office-based palliative care, palliative care in nursing homes, and home-primary care.

  • Capital Caring Health

    “Virtual Pediatric Multidisciplinary Rounds Enhance Regionwide Program Cohesion”

    Pediatric patients under concurrent care move back and forth between hospital and home/community care. Maintaining seamless communication is essential but can be a challenge when multiple providers in multiple institutions are involved. Pediatric programs often have few patients when compared to adult hospice in any community. Additionally, community-based programs often cover large geographic regions with many satellite offices, making in-person interdisciplinary team (IDT) meetings difficult. Adult providers continue to be less familiar with pediatric concurrent care practices than dedicated pediatric providers.

    Capital Caring Health set out to bring all pediatric RN case managers (RNCM) under one division, while simultaneously creating a strong partnership with the major tertiary children’s hospitals in their region. The team leveraged teleconferencing technology (Zoom) to allow RNCMs to present and discuss patients under the direction of pediatric specialists. This virtual rounding program incorporates representatives from each children’s hospital and RNCMs from each region, who report high satisfaction and program efficacy.

    Capital Caring Health - Tipping Point Challenge Top 25

  • Cedars-Sinai

    “Palliative Care for All: Improving Access Using a Population-Health Approach”

    While Cedars-Sinai has sought to increase palliative care utilization among cancer patients, there remains significant room for improvement. This project aims to proactively identify patients with complex oncologic needs, provide linkage to palliative care, support patient care delivery, and improve health outcomes through the development of an Oncology Risk Composite Score (ORCS).

    Upon implementation, the ORCS will monitor three different domains: 1) health care utilization; 2) patient-reported outcomes and screening; 3) and oncologic risk factors. Factors within each domain will be weighted to give both a domain and overall risk score, stratifying patients by risk level. A care coordination team will proactively reach out to identified patients and their care teams to implement necessary interventions, including palliative care consults, advance care planning, and other supportive care resources.

    Cedars-Sinai - Tipping Point Challenge Top 25 photo

  • Commonwealth Care Alliance

    “Promoting Primary Palliative Care Through Education and Standardized Documentation”

    Commonwealth Care Alliance (CCA) is a health plan that provides care management and care delivery for dual eligible Medicare and Medicaid beneficiaries in Massachusetts. The organization recognized an opportunity to improve its approach to advance care planning (ACP) by improving education, training, and related documentation standards.

    After CCA launched a chronic condition self-management program for CHF and COPD, which serves medically high-risk and behaviorally complex patients, they integrated ACP into the program. This solution has supported clinicians in addressing ACP, integrating members’ goals of care into their care plans. To do this, the team educated community-based advanced practice clinicians in communication skills to be able to conduct and document high quality ACP discussions.

    Commonwealth Care Alliance - Tipping Point Challenge Top 25 photo

  • Garnet Health Medical Center

    “Mitigating the ‘July Effect'”

    Each academic year, residency programs at Garnet Health Medical Center begin building a foundation of knowledge for their interns through boot camps, which focus on the “bread and butter” of the respective specialty. With management of patients living with serious illness often learned in the clinical setting, having this exposure is dependent on the intern’s schedule.

    To help with this, Garnet Health Medical Center sought to educate internal medicine (IM) residents on palliative care competencies at the beginning of the academic year, introducing the care of seriously ill patients early on through a series of lectures. The team evaluated the impact of these lectures through questionnaires, assessing pre- and post- lecture trends. Through the assessment, they learned of a positive trend in the post-lecture questionnaires. The result: proposing the incorporation of palliative care education in lectures and simulations in intern boot camps throughout the year.Garnet Health Medical Center - Tipping Point Challenge Top 25 photo

  • Helios Care

    “Choices: Innovative In-Home Palliative Care Program for Rural Underserved Population”

    There is lack of palliative care among marginalized, low-income rural communities. Whole person centered palliative care is rarely offered to rural patients, it is difficult to access in a community with a shortage of providers, and is hampered by limited funding for reimbursement.

    The Helios Care Choices program was designed to solve for this. Prior to the program’s launch, patients with serious illnesses were not receiving adequate symptom management, as psychosocial and economic challenges prevented access to medical care. This program provides free patient-centered, evidence-based palliative care to patients in their homes in three rural counties of New York State. With nursing, social work, and 24/7 telephone support for patients with serious illness, it has increased the comfort and quality of life for patients, while reducing health care costs.

    Helios Care - Tipping Point Challenge Top 25 photo

  • Indiana University School of Medicine; Moi University School of Medicine; Icahn School of Medicine at Mount Sinai; Dell Medical School, The University of Texas at Austin; Ascension St. Vincent Hospital; Living Room International; and Duke University School of Medicine

    “Training Initiative to Improve Palliative Care Accessibility in Western Kenya”

    The vast majority of Kenyans lack access to hospice and palliative care services, and the need is predicted to grow significantly in the next decade. To address this important population health challenge, the AMPATH consortium has identified the limited number of palliative care specialists as a major impediment to providing quality symptom management and end of life care. AMPATH seeks to increase access to palliative care in Western Kenya by developing palliative care training programs for health care professionals and Community Health Volunteers.

    To meet this need, the consortium has been developing training programs for nurses, clinical officers, and physicians. They have also been developing an innovative training program for Community Health Volunteers (CHV) to identify, provide care, and refer patients to palliative care providers. This program will imbed specialists throughout the health care system, thus providing care to those with little to no access. Training will include management, advocacy, and research skills to prepare graduates for roles in administration, government, or academia.

    This project is a collaboration between Indiana University School of Medicine; Moi University School of Medicine; Icahn School of Medicine at Mount Sinai; Dell Medical School, The University of Texas at Austin; Ascension St. Vincent Hospital; Living Room International; and Duke University School of Medicine.

    Indiana University School of Medicine + AMPATH - Tipping Point Challenge Top 25 photo

  • Institute for Human Caring, Providence St. Joseph Health

    “Optimizing Palliative Care through Reducing Clinical Variation (RCV)”

    After a call for initiatives by Providence St. Joseph Health to reduce unwanted clinical variation that challenge quality of care, efficiency, and costs, the Institute for Human Caring (IHC) responded with an innovative program. With the goal of improving palliative care clinical and program operations, they focused on three key objectives: increasing the percentage of PC referrals among non-OB adult inpatients (penetration); increasing the proportion of early inpatient PC consults; and decreasing the number of seriously ill inpatients with unmet need for PC. IHC built dashboards to track the metrics, while the palliative care team guided implementation.

    The Institute for Human Caring at Providence - Tipping Point Challenge Top 25 photo

  • Landmark Health

    “Landmark: Illuminating a population health pathway to value-based Palliative Care”

    Landmark Health is a risk-based, mobile medical group that cares for 140,000+ complex, chronically ill patients at home. It’s scalable palliative care focus proactively identifies those with serious illness, screens for needs and hospice eligibility and improves care through a holistic team-based approach.

    All patients under their care receive and benefit from elements of palliative care. Their challenge: How do they take a population health approach to find which patients need heightened attention to goals of care and holistic management (symptom assessment, psychosocial/spiritual care)? How do they match them to the right intervention?

    They approached this by: 1) reinforcing foundational palliative care skills and mindset for Landmark’s clinical team through training and local palliative physician leads and palliative social workers; 2) proactively identifying seriously ill patients before a crisis by combining predictive data analytics with clinician-driven assessments, and 3) leveraging technology-enabled operational and clinical workflows to manage patients in a consistent, scalable way.

    Landmark Health - Tipping Point Challenge Top 25 photo


  • Livestrong Cancer Institutes of the Dell Medical School, The University of Texas at Austin

    “The CaLM Model: Hardwiring Cancer Centers for Whole Person Care”

    Livestrong Cancer Institutes of the Dell Medical School is redesigning cancer care delivery around the needs of people living with cancer, and their loved ones. To do this, they are flipping the usual delivery system design to develop a person-centered “front-door” for cancer care. Their CaLM Model of Whole-Person Cancer Care™ anchors the cancer treatment integrated practice unit in supporting patients across the entire cancer continuum, so that all cancer patients receive the benefit of whole-person assessment, as well as access to sub-specialty palliative care from the point of diagnosis onward.

    Livestrong Cancer Institutes of the Dell University Medical School, The University of Texas at Austin - Tipping Point Challenge Top 25 photo 2

  • Mercy

    “Virtually Supported Complex Chronically Ill Patients”

    In 2015, Mercy launched their virtual program, vEngagement, to improve care and reduce high costs from preventable ER and hospital utilization. Through the program, a multidisciplinary telemedicine team follows patients with complex chronic disease. Beginning in 2019, this team expanded their skillset to provide holistic care for people living with serious illness through the systematic incorporation of a palliative care approach to care. Training, workflows, and direct collaboration with a specialty palliative care physician empowered the virtual team to grow their symptom management and communication skills. As a result, all vEngagement patients now have access to advance care planning, serious illness conversations, and specialty palliative care consultation from the comfort of their homes, increasing the likelihood of goal-concordant care as chronic disease progresses.

    Mercy Virtual - Tipping Point Challenge Top 25 photonce St. Joseph Health

  • Moffitt Cancer Center

    “What Matters Most: NICHE-AFHS Interprofessional Project at Moffitt Cancer Center”

    In pursuit of an Age Friendly Health System (AFHS), the Moffitt Cancer Center team chose to address “What Matters” to the cancer patient. In addition to asking and aligning care with each older adult’s specific health outcome goals and care preferences, they included end-of-life care preferences across the system, with question prompts that differed depending on the clinic and setting. For instance, in acute care settings, “What matters most today?” was asked every day on a whiteboard in patient rooms.

    What started as low-tech paper made way for documentation in the electronic health record. The necessity for advanced directives and surrogate designation to be available to the health care team led to a design that provided a series of educational activities. This series empowered the nursing team to start the conversation and complete documentation of end of life preferences.

    H. Lee Moffitt Cancer Center and Research Institute - Tipping Point Challenge Top 25 photo

  • NYU Langone Health

    “Screening Question on Discrimination for Inpatient Palliative Care Consults”

    Systemic discrimination as a problem within the health care system is already known. The role of a palliative care provider is to identify and alleviate distress in patients with serious illness, though discrimination is not a standard part of the palliative care or medical assessments. Spurred by the murder of George Floyd, NYU Langone Health’s inpatient Palliative Care team sought to address this gap in understanding and practice. Through several iterations, their workgroup added a mandatory screening question to the initial consult: “During previous medical encounters have you ever felt that you were treated differently from other patients for any reason?” Their goal was to elicit patients’ perceptions or experiences of inequalities in any health care system, and provide therapeutic presence and listening. The lack of research in this area makes this quality improvement project necessary for the advancement of our understanding of and improvement in medical inequities.

    NYU Langone Health - Tipping Point Challenge Top 25 photo

  • NYU Rory Meyers College of Nursing and The New Jewish Home

    “Uncovering Palliative Care Need in a Medicaid-funded Assisted Living Facility”

    This primary palliative care quality improvement effort identifies and addresses palliative care need in a marginalized, frail, and vulnerable assisted living population. This project is an academic, public housing partnership between NYU Rory Meyers College of Nursing and The New Jewish Home (NJH). It seeks to leverage quality improvement and palliative care expertise to reduce suffering in older adults with serious illness living in an established Medicaid Assisted Living Program (ALP) in the Bronx.

    The submitting author, an RN from NYU, is embedded within the wellness center of NJH (2 times per week), uncovering palliative care need; evaluating care processes; providing education to residents and care staff; and introducing interventions to address symptoms of serious illness, support advanced care planning, and reduce avoidable hospitalization.

    NYU College of Nursing and The New Jewish Home - Tipping Point Challenge Top 25 photo

  • Optum CA

    “Optum CA Outpatient Palliative Care Program”

    In 2019, Optum CA revamped their supportive care program, leveraging industry best practices to maximize access to high-quality palliative care for patients in their last year of life. Building on a foundational program launched in 2008, the key new features include: 1) adopting an outpatient focus (clinic and home visits); 2) leveraging data science models to identify patients’ 12-month mortality risk, engaging patients earlier in their disease trajectory; 3) forming a robust interdisciplinary team with a “care partner” role (a nonclinical, hired surrogate family member who helps the patient/family with care management); and 4) clearly defining and distributing discrete outcome metrics in monthly dashboards.

    Optum CA - Tipping Point Challenge Top 25 photo

  • Parkland Hospital and UT Southwestern Medical Center (1)

    “Mass Production of Compassionate Communication in the Era of COVID-19”

    In March 2020, Parkland Hospital opened its COVID ICU (“ICU”) for patients who required mechanical ventilation. Despite high risk of mortality, patients were separated from their families due to necessary, but prohibitive, visitation policies. The ICU and palliative care teams (the latter, staffed primarily by UT Southwestern Medical Center physicians) created a novel care model, which facilitated daily communication with families of over 500 patients in the ICU (from March 2020-2021). The team assembled a network of physician volunteers to “adopt” ICU families and generated scripts to facilitate formation of a therapeutic alliance, counseling regarding prognosis and COVID-specific complications, exploration of values, delivery of recommendations regarding treatment options, and provision of emotional support. Members of the palliative care team rounded with the ICU team, assisted with symptom management, and coached volunteers. These strategies allowed the team to double the typical daily census of the palliative care team with no increase in staffing resources.

    Parkland Health System - Tipping Point Challenge Top 25 photo

  • Parkland Hospital and UT Southwestern Medical Center (2)

    “Texting to Find the Tipping Point”

    With a robust palliative care ambulatory clinic in a large county hospital, patients are often referred to the Parkland Hospital/UT Southwestern Medical Center palliative care team at the time of diagnosis. While the team may follow these patients for years, it’s often the patient’s instinct to go to the ED when they start to take a sharp downturn in performance status – rather than reaching out to the clinic.

    This team believes that they can detect problems earlier by reaching out to their ambulatory patients, rather than waiting for them to reach them. The population has demonstrated little interest in MyChart or email, but are very comfortable with texting. Due to this, the team plans to send a short weekly questionnaire via text to all ambulatory patients, asking a general well-being score and whether they need a return phone call. The team will use this data to intervene before a crisis occurs in their racially diverse, socioeconomically disadvantaged population.

    UT Southwestern Medical Center at Dallas - Tipping Point Challenge Top 25 photo

  • Porter Adventist Hospital (1)

    “Impact of Early Palliative Care Consultation (EPCC) During the COVID-19 Pandemic”

    Less than a month after the first COVID-19 Patient Under Investigation (PUI) was admitted to Porter Adventist Hospital, multiple rapid responses occurred on the COVID-19 medical floor requiring crucial ICU resources. Critical care and internal medicine physicians met briefly with palliative care (PC) Advance Practice Nurses (APRNs) to discuss the gap in early identification of goals of care. A collective decision was reached that every PUI would receive an automatic PC consult order.

    The PC APRNs developed an innovative approach by requesting internal medicine hospitalists place PC consult orders upon admission while the PUI was still in the ED. Regardless of age, race, or co-morbidities, all PUIs were referred to PC, even though they may not have been referred to PC in another circumstance. EPCC resulted in more patients establishing decision-makers and goals of care prior to decompensation, thus helping patients avoid potential suffering caused by unwanted medical interventions.

    Porter Adventist Hospital, Centura Health - Tipping Point Challenge Top 25 photo for COVID initiative

  • Porter Adventist Hospital (2)

    “Impact of a 2-Hour Intervention on Clinical Practice in End-of-Life”

    Surveyed Americans report a preference to die at home; however, most die in institutional settings. Patients who are dying in the hospital have higher physical and emotional discomfort, lower quality of life, and prolonged grieving amongst caregivers; this population represents a vulnerable population requiring a specialized nursing skillset by acute care staff. Nurses report a lack of undergraduate training.

    At Porter Adventist Hospital, an acute care hospital, a lack of knowledge and confidence was revealed in providing care to patients at end of life. To solve for this, the palliative care (PC) Advance Practice Nurses (APRNs) developed a 2-hour educational intervention for bedside nurses. After training, the nurses were able to demonstrate improved knowledge and self-efficacy. Research is underway to find the impact on clinical practice, with the hope to change nursing practice to improve the experience for the patient and family.

    Porter Adventist Hospital, Centura Health - Tipping Point Challenge photo, project 2

  • Sarasota Memorial Hospital

    “Primary Palliative Care RN Resource Team”

    In 2018, an internal survey at Sarasota Memorial Hospital revealed that 86% of bedside nurses desired to learn more strategies to care for patients with serious medical conditions, including end of life care. As a result, a partnership evolved between oncology, nursing leadership, and the supportive care team (palliative care) to develop a team of strong RN peer mentors to extend the reach of palliative care systemwide. The program included the use of CAPC online resources, in person education, and the commitment of ongoing mentorship from the established Supportive Care team.

    Sarasota Memorial Hospital - Tipping Point Challenge Top 25 photo

  • St. Tammany Health System

    “Culture Shift Change within Rural South Louisiana Health System”

    St. Tammany Health System (STHS) cares for a rural and suburban population; this includes Tangipahoa and Washington Parishes, which have respectively 24.9% and 21.7% of their populations living in poverty (per the U.S. Census Bureau). This compares to a statewide poverty average of 19.0% within Louisiana. These marginalized populations historically have had limited access to health care services.

    STHS’ initiative aims to improve alignment of medical care received with the care desired by this marginalized, rural population. The goal is to improve integration of advanced care planning (ACP) services within the acute and post-acute settings for these communities. This included having the palliative care team broadening their scope to create a more comprehensive service, spearheading the standardization of ACP documentation.

    St. Tammany Health System staff photo

  • The Narrative Initiative and St. Luke's University Health Network

    “Serial Interdisciplinary Write-Read-Reflect Narrative Experiences Meaningfully Strengthen Reflective Listening Skills”

    “Enhancing listening and communication skills” is a crucial component of hospice and palliative medicine staff core competencies, in order to successfully provide care that providers, patients, and families perceive as “good care.” St. Lukes University Health Network (SLUHN) asked themselves, “How do we learn and practice robust reflective listening skills that can be immediately put into practice to improve the patient-provider/provider-colleague experience?”
    To solve for this, SLUHN conducted an interdisciplinary IRB-approved study employing a series of Write-Read-Reflect narrative experiences to the curriculums for residents/fellows of HPM, Pastoral Care, and Psychiatry programs (through The Narrative Initiative). Using their own short stories on a series of advancing topics, they learned and practiced selecting and reflecting specific words that rapidly open up a conversation to determine what is important. They reported planning to make behavioral changes in what to listen for with patients and colleagues. Other reported benefits included decompression and enhanced resilience.

    The Narrative Initiative - Tipping Point Challenge Top 25 photo

  • The University of Mississippi Medical Center

    “From Service to Center: Leading Palliative Innovations for Complex Populations”

    The University of Mississippi Medical Center’s (UMMC) palliative care team mission led them from small service to home-building for medically complex children and establishing an accountable care system for under-resourced populations.

    After UMMC’s palliative care team established a service in pediatrics, they realized that the majority of patients needing compassionate goals of care and symptom management were children with medical complexities. The team discovered that, in order to support their patients (and their families) quality of life, they would have to re-imagine the scope of a palliative care team. They began leading care for vent-dependent children who lived at home or in the hospital without the means to get home, and evolved their service into an inpatient and outpatient medical center for these children, and grew from a service of 70 to 1200 in just 5 years. Now, they are now partnering with the Mississippi State Legislature, Medicaid, and institutional leaders to build a home for medically complex children. They are also launching an accountable care coordination pilot project with Medicaid to serve this population.

    University of Mississippi Medical Center - Tipping Point Challenge Top 25 photo

  • Tufts Medical Center and Merrimack Valley Hospice

    “Overcoming End of Life Disparities through Community Engagement and Education”

    This innovative community outreach initiative between Tufts Medical Center palliative care and Merrimack Valley Hospice successfully engaged the Boston elderly Chinese American community conversation around serious illness, advance care planning, and end of life.

    The palliative care team at Tufts started by identifying and addressing disparities in end of life care for traditionally underrepresented populations – through education specific to serious illness, such as cancer, end of life care and planning, and grief and bereavement. Through the early identification of the local Chinese-American immigrant community, the team fostered civic learning, completed a needs assessment, and educated and engaged the population in their health care.

    This initiative enabled Chinese American community members and medical providers to engage in dialogue around sensitive/taboo topics, and represents a successful collaboration between a palliative care program and community-based non-profit organization serving elderly population in Boston’s Chinatown.

    Tufts Medical Center and Merrimack Valley Hospice - Tipping Point Challenge Top 25 photo

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