LifeCourse at at Glance

Approach. Built on tenets of palliative care, LifeCourse provides a whole person supportive approach.

For Who?  Patients in the last few years of advanced serious illness.

How are They Identified?  LifeCourse-developed algorithm using electronic health record data and/or provider referral.

Who Provides the Service?  Community health workers, called care guides, attach to existing health care teams. Care guides have strong communication skills and compassion for those living with serious illness; a minimum of a high school degree; post-secondary education preferred.

What Do Care Guides Do?  Meet with patients monthly in their home to facilitate conversations that:

  • Promote whole person care by using a clearly defined visit framework with question sets and standardized assessments to lead discussion of patients’ medical and non-medical concerns.
  • Help patients articulate what matters most to them and supports patients and families in seeking care that aligns with the patients’ goals and preferences.
  • Use a community-oriented approach to connect patients and families to social services and community-based resources.

How is it Reimbursed?  Varies by locality, such as patient-centered medical home coordination fee, value-based payment, and Medicare Advantage plans.

Impact: Improved quality of life and experience of care. Reduced total cost of care.