Background: Patients with chronic and serious illness frequently experience fragmented outpatient follow-up, poorly controlled symptoms, and repeated emergency department (ED) visits. These preventable episodes often reflect missed opportunities for earlier intervention, care coordination, and proactive goals-of-care discussions. Chronic Care Management (CCM) and outpatient palliative care can support these patients, yet many internal medicine practices struggle with implementing both programs simultaneously due to staffing limitations, workflow disruptions, and complex reimbursement requirements. Models that improve coordination between outpatient teams and hospitalists may help reduce acute care utilization and improve continuity.
Purpose: To describe the implementation of an outpatient CCM–palliative care innovation within an internal medicine practice and evaluate its early impact on acute care utilization, chronic disease control, and communication between outpatient clinicians and hospitalists.
Description: A pilot program enrolled 32 medically complex patients with uncontrolled hypertension, diabetes, chronic lung disease, heart failure, or high symptom burden. CCM services included structured monthly outreach, medication reconciliation, specialist coordination, anticipatory guidance, and telehealth check-ins. Patients with repeated ED visits or advanced illness were offered outpatient palliative consultations focusing on goals of care, early symptom management, and crisis prevention.A communication workflow was created so that when an enrolled patient was admitted, the hospitalist team automatically received a summary of recent CCM or palliative encounters, current care goals, and medication adjustments. This improved transitions, reduced duplicative work, and supported alignment between inpatient and outpatient plans.Early 90-day outcomes included:ED visits decreased from 18 → 10, a 44% relative reduction.Hospitalizations declined from 9 → 6.Mean systolic BP improved from 154 → 143 mmHg.Fasting glucose decreased by 12 mg/dL.Among 11 palliative patients, families reported fewer “crisis visits,” improved symptom control, and clearer care expectations.Challenges included CCM billing complexity, variable patient engagement, and high care coordinator workload. Facilitators included telehealth flexibility, interdisciplinary teamwork, and timely communication with hospitalists during admissions.
Conclusions: An integrated CCM-palliative care model is feasible and may reduce avoidable acute care utilization while improving chronic disease control. Early findings show fewer ED visits, fewer unplanned hospitalizations, and stronger continuity between inpatient and outpatient teams. Dedicated staffing, streamlined reimbursement workflows, and structured communication channels may support broader adoption of this model within hospital medicine. This pilot highlights how proactive outpatient care can prevent crisis-driven episodes and reduce hospital burden in medically complex patients.