In-home palliative care significantly increased patient satisfaction while reducing use of medical services and costs of medical care at the end of life. This study, although modest in scope, presents strong evidence for reforming end-of-life care.

Through integrating palliative care into curative care practices earlier in the disease trajectory, chronically ill patients nearing the end of life report improved satisfaction with care and demonstrate less acute care use resulting in lower costs of care. In addition, patients enrolled in the palliative care program were more likely to die at home than comparison group patients.

Provision of interdisciplinary home-based palliative care at end of life can effectively increase the likelihood of dying at home for patients with CHF, COPD, and cancer while realizing significant cost savings.

INTRODUCTION T HE VA ST MAJORITY OF AMERICANS who die eachyear are elderly patients with a median age of 77 years, typically suffering from slowly progressive, chronic diseases. 1 Most Americans will have lived with an average of 2.2 chronic conditions for 17 years by the time of their death. 2 The effects of chronic conditions such as cardiovascular disease and diabetes are felt physically, emotionally, and financially and place the patient at greater risk of serious health complications and disability. 3,4 Our society's ability to afford health care depends heavily on our ability to control long-term care costs incurred at the end of life. In turn, cost control depends on our ability to manage chronically ill patients effectively. This paper discusses the unique advantages of managed care organizations (MCOs) in developing and financing innovative systems for managing long-term and end-of-life care, presents an innovative model of end-of-life care pioneered by one MCO, and suggests future recommendations. UNMANAGED CARE: A NO-WIN SITUATIONCurrently, patients with a chronic disease experience fragmented care, with multiple specialists often separately managing care at various times and sites, typically with little communication among themselves. Patients and their families manage the transitions among various providers, disease specialists, financial systems, and care settings on their own. 5Of the roughly 2.4 million Americans who die each year, 75% are insured by Medicare at the time of their death. 6 Among these patients, approximately 50% of last-year medical costs are incurred in the last 60 days of life, and 40% in the last 30 days of life. 7 Despite older persons' preference to receive end-of-life care at home, 8 only 20% of deaths occur at home; most other deaths occur in hospitals (57%) and nursing homes (17%). 9Our current system for managing end-of-life care is dysfunctional. If we started anew, what would characterize "good" end-of-life care? Lynn and Schuster 10 and Cassel and Foley 11 have generated separate lists of key principles of care that reflect a reassuring degree of consensus. They strongly imply that a coordinated, interdisciplinary team approach is a prerequisite to achieving good end-of-life care. Such an approach is a hallmark of MCOs, and one reason they are now at the forefront of developing and financing improved models of end-of-life care. MCOS: COORDINATING CARE ACROSS THE CONTINUUMThe fiscal structure of MCOs offers unique opportunities to develop and test innovative methods for managing end-of-life care. As capitated systems, MCOs have the financial and organizational flexibility to integrate all elements of health care-from physicians to financing-into a coherent whole. As Lynn et al. 5 note, "Advantages derived from managed care systems providing quality end-of-life care include coordinated care across delivery sites, interdisciplinary teams, in-

Introduction: Studies show that home-based palliative care (HBPC) improves participant outcomes and satisfaction with care while also decreasing hospitalizations and emergency department visits. U.S. health care payment reforms create financial opportunities to offer HBPC. Consequently, more HBPC programs are emerging, heightening the need to evaluate their effectiveness. Methods: This randomized, controlled trial is comparing the effectiveness of an evidence-based model of HBPC and enhanced usual primary care for participants who receive primary care from medical groups and clinics organized under an accountable care organization or Medicare Advantage plan. Palliative care services are reimbursed by our partnering health plan provider. The five-year trial will enroll 1155 seriously ill participants (and *884 of their caregivers) with heart failure, chronic obstructive pulmonary disease, or advanced cancer. We are collecting data via telephone surveys with participants at baseline and one and two months postenrollment and with caregivers at baseline, one and two months postenrollments, and following the death of a loved one. We are collecting participant-reported outcome measures of pain, symptoms, anxiety, depression, participant-provider communication, and hope. Caregiver outcome measures include caregiver burden, communication with providers, anxiety, and depression. Additional outcomes are participant survival time and participants' emergency department visits and hospitalizations. Study Implementation: Challenges and Contributions: Our research team has encountered several significant challenges in early study implementation. These include engaging primary care providers in the study and coordinating logistics with a health plan. Both challenges have contributed to a lag in participant enrollment. Despite these challenges, our study holds tremendous promise to accelerate adoption and spread of an evidencebased HBPC model across the country.