Mass General Brigham uses AI to bring palliative care to more patients, sooner
Mass General Brigham wanted more of its seriously ill ACO patients to reach palliative and hospice care in time. In a pilot at Newton-Wellesley Hospital, Radial Care flagged, on the first day of a hospital stay, the patients who stood to benefit, and the care team acted: inpatient palliative care consults rose by 24%, and users agreed with 92% of the recommendations.
24% more inpatient palliative care consults in five months
Users agreed with 92% of Radial Care's recommendations
$850,000 in potential savings over five months, $2 million per year
The challenge: too few patients reach palliative and hospice care, and too late
The science is clear that timely palliative and end-of-life care helps patients: better quality of life, survival and mood, a better chance of being at home at the end of life, fewer avoidable hospitalizations, and a better experience for bereaved families. Yet nationally, too few patients are referred to palliative care or hospice, and those who are often come too late.
Mass General Brigham (MGB) saw the gap in its own data. More than 10% of its Medicare Shared Savings Program (MSSP) ACO members died within 30 days of leaving a skilled nursing facility (SNF), and for members with three or more SNF stays, 90-day mortality approached 30%. Timely palliative and hospice care became part of MGB's "Right Patient, Right Place, Right Time" initiative, led by its Population Health Management team, alongside home-first care, more inpatient capacity, and keeping scarce SNF beds for the patients who need them most.
- 10%+
- of MGB MSSP ACO members died within 30 days of leaving a skilled nursing facility
- ~30%
- 90-day mortality for members with three or more skilled nursing facility stays
The opportunity at Newton-Wellesley Hospital
MGB chose Newton-Wellesley Hospital (NWH), a 273-bed community teaching hospital in Newton, Massachusetts, as the first site. Its staffing and population health programs were already in place, and MGB ACO and NWH teams were already managing care together across the continuum, including post-acute and end-of-life care.
Before launch, an analysis found NWH's hospice referral rate slightly below the national median. Raising it from 3.7% to 4.2% would mean 15 more hospice referrals per year, a savings opportunity of $411,825 per year for the MGB MSSP ACO, at $27,455 in total medical expenditure saved for each additional hospice enrollment.
The solution: Radial Care finds the patients "on the border" on day one
A hospital stay is often when patients and families are most open to a conversation about their goals of care, and outpatient providers can feel ill-equipped to start one. Radial Care's hospice and palliative care module, then called Smart Hospice, uses machine learning to flag, on the first day of a hospital stay, the patients who stand to benefit from a timely palliative care or hospice assessment, with the clinical reasoning that brings population health, inpatient and palliative teams together. It asks for no data entry.
Treatment is clearly right
For some patients, therapeutic interventions are appropriate and the plan is clear.
Where Radial Care focuses
On the border
Non-obvious patients at risk of unnecessary or potentially harmful interventions, who may be approaching the end of life. These are the patients Radial Care recommends for a palliative care or hospice consult.
Comfort is clearly the focus
For some patients, the need for palliative care or hospice is clear, and the focus is their quality of life.
In practice: a six-month pilot with a clear workflow
MGB and NWH launched a six-month pilot for MSSP ACO members hospitalized at NWH, with success criteria set in advance: users agreeing that the recommendations were appropriate, user satisfaction, the share of recommended patients who received an inpatient palliative consult, and the rate of discharges to hospice.
- 1
Transitions Care Management team
Uses Radial Care every day, reviews the recommended patients in Epic, discusses them with the care team, and refers them to the palliative care team on hospital day 1 or 2.
- 2
Palliative care team
Decides whether palliative screening is appropriate and, if so, considers an inpatient palliative consult, outpatient palliative services or hospice.
- 3
Palliative and hospice services
Work with the patient, family and care team, in partnership with the Transitions Care Management team, to decide the next steps.
The results: 24% more inpatient palliative care consults
Over five months, Radial Care recommended 135 of the 1,522 MGB MSSP ACO members hospitalized at NWH for a palliative consult, and 40 of them received one. Users judged that 17 of those consults, a 24% boost, would have been missed without Radial Care.
By January 2024, four of the 17 patients were enrolled in hospice, seven were considering it, two had not yet discussed it, and four had died without hospice. If all 13 living patients reach timely hospice care, the savings in total medical expenditure would come to $850,000 over five months, equivalent to $2 million per year.
| Step | Patients |
|---|---|
| MSSP ACO members hospitalized at NWH over five months | 1,522 |
| Recommended by Radial Care for a palliative consult | 135 (9%) |
| Received an inpatient palliative consult | 40 (30% of those recommended) |
| Consults that would have been missed without Radial Care | 17 |
What users and staff said
Users agreed that 92% of the patients Radial Care recommended could be suitable candidates to screen for palliative care, or hospice where appropriate. Staff surveys of the palliative care, hospitalist, case management and ICU teams, before and after the pilot, showed concrete gains: physicians were much more likely to ask the "surprise question", felt more confident judging whether a patient needs a palliative consult, worked more closely with case management, and were less likely to cite barriers to involving palliative care.
- +25%
- more felt inpatient palliative care use was “just right”
- +25%
- more felt they had the right tools and information to justify a palliative consult
- +23%
- more said good workflows were in place to identify patients for palliative care
- +14%
- more found it easy to refer to the inpatient palliative care team
Staff surveys before the pilot (May 2023, 30 responses) and after it (November 2023, 15 responses).
"Connection it has built between palliative care and TCM [staff]"
"The clear overview the insights section provides of the patient's needs"
One patient's story
A woman over 90 with a recent blood clot in her lungs came to NWH with shortness of breath, fatigue and signs of bleeding. Radial Care recommended her for a palliative consult, noting two recent emergency visits and three hospital stays, serious heart, kidney and other conditions including dementia, a do-not-resuscitate order on record, and a palliative care discussion in the past year. The palliative care team agreed.
The hospitalist hesitated, worried about alienating the family, who favored a procedure that the gastroenterology team considered risky. The palliative care team offered to help the family weigh the procedure against the patient's values, and the hospitalist placed the referral. A palliative care provider met with the patient and her daughter for 90 minutes. Together they decided the procedure was not in her best interests, and they were open to talking further about hospice.
What MGB learned
- Strong buy-in, collaboration and communication across the continuum, and tight teamwork between NWH, MGB Population Health and Radial, made the pilot work.
- The Transitions Care Management team is better educated and more confident deciding whether a patient needs inpatient or home-based palliative care.
- A hospital stay can be used to start conversations about goals of care, setting up the patient's longer-term providers to continue them after discharge.
- The pilot also showed a need to support patients with frailty or a downward trend who don't yet need a palliative care consult.
What's next
Users asked for Radial Care to find patients earlier in their illness, and to reach into primary care, where many of the patients identified would benefit from home-based palliative care. MGB took that next step: it later used Radial Care to find patients for its home-based palliative care program and to measure what the program delivers, in a case study presented at AAHCM 2025.
As presented at the National Value-Based Payment Summit, February 2024
Amy Baughman, MD, MPH, Medical Director, Care Continuum, Mass General Brigham, and Kaitlyn Schweikert, Population Health Program Manager, Newton-Wellesley Hospital, with Anant Vasudevan, MD, MBA, Chief Medical Officer, Radial
Radial technology development was funded in part by the National Science Foundation and the National Institutes of Health.
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