Palliative Care for Serious Illness, Hospice, and Advance Care Discussion

By November 2025, an interdisciplinary, palliative care–led intervention was developed to address the complex needs of polychronic, high-cost, high-need patients, reducing acute utilization by 25%. Led by trained palliative care subject matter experts (SMEs), the model focused on lowering costs and avoidable readmissions, improving care transitions, increasing appropriate hospice referrals, strengthening primary palliative care skills, and enhancing interdisciplinary collaboration. Improvements in deprescribing, continuity of care, teamwork, and hospice conversion demonstrate that coordinated multidisciplinary support and provider education improve outcomes and resource efficiency in home-based care.