Expanding Advance Care Planning in the Safety Net
Chicago-based Medical Home Network (MHN), a public benefit corporation focused on transforming care in the safety net, is partnering with Koda Health to expand access to advance care planning across federally qualified health centers (FQHCs).
Koda Health has developed a digital patient decision support platform that enables health systems and payers to scale up end-of-life conversations. Following a recent rollout in Oklahoma, MHN, which works with more than 80 FQHCs in eight states, plans to expand the initiative to additional sites.
Koda CEO Tatiana Fofanova, Ph.D., and Chief Medical Officer Desh Mohan, M.D., recently spoke with Healthcare Innovation, along with MHN Chief Medical Officer Henish Bhansali, M.D.
Founded in 2020, Koda Health’s solution guides patients through the process of proactive healthcare planning, facilitates patient-caregiver alignment, auto-generates legal documents (such as Medical Power of Attorney Forms and Advance Directives) and virtually notarizes these documents at no cost to patients. Customers include Cigna, Memorial Hermann, Houston Methodist, Guidehealth, Privia, Sentara and Blue Cross Blue Shield of South Carolina.
In February 2024, Healthcare Innovation interviewed MHN CEO Cheryl Lulias about the organization’s value-based care focus.
Healthcare Innovation: Desh and Tatiana, I read that you took part in the Texas Medical Center’s Biodesign program. Can you talk about how that helped foster the idea for Koda Health?
Mohan: We had the opportunity to participate in the founder-in-residence program at the Texas Medical Center, which is just phenomenal. It provides the opportunity for founders like Tatiana and myself to come together to really understand the root problems within health systems. We had the opportunity to spend time in large institutions like MD Anderson, Houston, Methodist, Memorial Hermann — all the way from the C-suite to patients and family members and frontline staff. One of the things that we saw over and over again was that patients ended up in the hospital or in critical care settings and hadn't had the opportunity to express what mattered to them. They were often receiving care that was misaligned and not what they wanted in the first place. So our goal at Koda after that was, how do we make it easier for patients to really express and receive the care that mattered to them most?
We realized that it was very difficult for providers to elicit those preferences in advance, and we built Koda to make it easier for both patients and for providers to have a streamlined way to understand and define preferences, so that ultimately patients get the care that matters most to them when they're facing serious illness. We started the company in March of 2020, and that's right when COVID struck. So it became that much more real, because it became so much harder to have these conversations face to face. That really accelerated the intensity of the work that we were doing. Since then, we've been growing and providing services nationwide to over a million patients, so we are excited about the impact that we're making.
HCI: Is there a an equity component to this? Are people from poorer communities less likely to have advanced care plans than people who are better off?
Fofanova: I feel very passionately about this. Yes, absolutely, countless studies suggest that people who are of lower socioeconomic status or background have less access to this. Patients who come from minority populations have less access, whether that is due to cultural differences or fear of authority, bias or information disparity, or just access. Then there are some surprising populations — older men tend to engage in advance care planning less often, simply because of discomfort with a face-to-face conversation about the topic.
Our approach, which is really digital-first, offers a patient decision support platform that they can access at home, in the clinic — wherever they are. We have shown that we are able to engage patients at equal levels across race, gender and socioeconomic status, which is incredibly important to us, because if we're looking at the overall population, those are the folks who are the most underserved, who have the largest gap in advance care planning and often get care that is unwanted or inappropriate or often goes against their preferences.
HCI: Dr. Bhansali, in the FQHC settings that you work in, has there traditionally been a low level of advance care planning taking place?
Bhansali: The number of patients who engage in advance care planning in that setting is substantially lower, and in many ways, this is where the need is substantially higher. So this partnership with Koda makes complete sense for us.
One of the formative books for me was Atul Gawande’s “Being Mortal.” One of the key things he said in that book is that what people want for themselves is freedom. What people want for the ones they love is safety. And if people are not making decisions for advance care planning, then often it is incumbent on those who have no idea what to do when the patients can't make the decision to piece things together. And often people just don't want to feel guilty for not doing something. Within that context, people often do things that just are not in the best interest of patients. My personal thesis as a clinician is that we want people to live and die on their own terms. What we're looking for through advanced care planning is much better patient outcomes and patients having their wishes about how they want to live the rest of their lives honored.
HCI: Does this also feed into your value-based care strategy, in that it could reduce the number of hospitalizations at end of life — and maybe hospitalizations that people don't even really want?
Bhansali: It's hospitalizations, ER visits, it’s people getting chemotherapy within the last 15 to 30 days of life that is not palliative. There's palliative chemotherapy, but there's curative chemotherapy that is not needed.
MHN is working with CMS and CMMI and thinking through does something like this make sense as a quality measure to say, how do we have anyone within the Medicare program think through what they want for themselves, so that you minimize things that are really low value — it just creates more harm than good. How do we minimize that towards people's end of life?
HCI: I read that you started the partnership working in Oklahoma. Did you have to figure out how to get it into the clinical workflow?
Bhansali: There are some generalities, but there are specifics and nuances to each one of these practices. And the Koda team has been phenomenal in thinking through how we're going to operationalize this. We have 19 different FQHCs in Oklahoma, and we have 19-ish different ways of how we're going to do this. Our goal is to first focus on the highest risk patients and figure out where we can integrate this into the workflow. During a visit, if the clinician or a member of the care team brings this up and does a warm handoff, that is by far one of the best ways to actually get this done.
HCI: Did the Koda Health team think a lot about this workflow issue?
Fofanova: We are very multi-modal, and we go to where the patient is. Not all providers are very comfortable introducing this conversation. Not all patients are comfortable having a face-to-face conversation. So one of the benefits of Koda is that we can reach people through a variety of ways. We can reach them through MyChart or the EMR. We can reach them through a provider referral. If a provider makes that referral, we can reach them through e-mail, through text. We do call campaigns. We have digital materials and marketing materials that we send out, and all of it points to the same patient decision support platform for them to make their preference decisions, document them, and everything is integrated into the workflows and the EMRs of the organizations we work with.
HCI: I see that you have partnerships with health plans as well as large health systems.
Fofanova: That's right, nationwide we're providing services to large health plans, large regional health systems, value-based providers and enablers and fee-for-service systems.
I think one of the things that's most important right now is the timing. We really have a silver tsunami with the population aging into Medicare. When you really consider that 25% of Medicare spend occurs in the last year of life, and much of that is misaligned or unwanted care, there’s a real disconnect that occurs there. I think a priority even for past administrations, but really accelerated with CMS now is how do we ensure we're delivering patient-centered care in a cost-effective, efficient manner? I think that's one of the core tenets of value-based care, and our results have been able to demonstrate that for patients receiving advance care planning through Koda, we're able to ensure that they're receiving goal-concordant care. That means reduced admissions to the hospital by 79% when it comes to terminal admissions, and significantly reduced unnecessary ICU utilization, and that results in around a 19% total cost of care reduction in the last year of life.
