How integrated Supportive Care services help patients as their care needs escalate.

In my last post I explored how proactive navigation and triage can reduce emergency department (“ED”) use among oncology patients. But there comes a point where these strategies, while vital, are no longer sufficient. As patients progress up what I call the “severity ladder,” their needs outgrow standard responses. Their symptom burden intensifies, psychosocial stress mounts and their prognosis often changes. At this pivot point, oncology practices must shift from reactive logistics to anticipatory support. The next operational question becomes:

How do we walk with our patients through this phase, both compassionately and sustainably?

The answer is a high-functioning, well-integrated palliative and supportive care program: a structure that helps patients live as well as possible for as long as possible while simultaneously improving value-based and clinical quality performance.

Redefining the Narrative: Palliative Care ≠ Giving Up

Despite two decades of education, palliative care still carries stigma. For some clinicians and many patients, it connotes failure or withdrawal.

“Palliative care works best when it enters the patient’s journey early. Too often, we are called in the last days or hours, but our greatest value lies in walking with patients through the hard parts. We are not just managing symptoms but also supporting the emotional and practical toll of serious illness. Our goal isn’t to take over. It’s to make sure no one feels abandoned. Interdisciplinary teams can do more and patients deserve that partnership.”

Veronica Sudekum, M.D.

Physician, Supportive Care

Central Georgia Cancer Care

American Oncology Network

Forward-thinking practices are therefore renaming these services “Supportive Care Clinics,” or “Quality of Life Services,” for example, and introducing them not at the end, but at diagnosis. The shift in semantics reduces patient resistance and facilitates earlier, more effective interventions.

Tracking What Counts: Quality vs. Value Metrics

High-performing practices must learn to differentiate between compliance and impact. Quality metrics measure process adherence: Was the pain screening done? Was the POLST discussed? Value-based metrics reflect outcomes: Did palliative involvement reduce ICU stays? Did earlier advance care planning reduce late ED visits?

The ASCO OMH Standard reflects this distinction. It outlines expectations around hospice utilization, acute care use in the last 30 days of life and timely documentation of goals-of-care conversations. These are not soft metrics—they are hard benchmarks that influence reimbursement, public reporting and payer negotiations.

Addressing the Psychosocial Front

What’s often underappreciated in oncology transformation is the psychosocial terrain that patients and families must navigate. Financial toxicity, food insecurity, unstable housing, transportation barriers and insurance confusion are not side issues, they are care-limiting issues. A patient may delay treatment not because of ambivalence but because they can’t afford transportation or have no childcare. Dr. Sudekum notes, “We see patients who gain weight in the hospital because they’re finally getting regular meals, only to lose it again when they go home to food insecurity.”

As cancer progresses, the psychosocial burden intensifies. A 2022 review in General Psychiatry documented the impact on self-concept, body image and social identity, with patients reporting feelings of stigma, isolation and existential anxiety. These aren’t intangible experiences, they manifest in real-world behaviors like missed appointments, medication non-adherence and emergency use. Practices that build interdisciplinary models including social workers, psychologists and financial counselors create a stronger, more cost-effective framework for care delivery.

Financial Viability Through Accurate Billing

Supportive and palliative care do not have to operate at a loss. When structured correctly, they drive downstream cost savings by avoiding preventable hospitalizations and aligning treatment with patient goals.

The 2025 CMS update strengthens the billing foundation for supportive services. Advance care planning (CPT codes 99497 and 99498) is reimbursable on the same day as oncology services, provided documentation supports time and content.

Medicare Advantage plans increasingly permit concurrent hospice and treatment pathways. Yet operational uncertainty about documentation, code stacking and workflow disruption continues to stall implementation in many settings. Practices that invest in provider education, compliance support and billing workflows will have a measurable advantage.

AI-Enhanced Referral Models and Dashboards

Staffing constraints remain one of the greatest barriers to supportive care growth. But technology is closing the gap. Leading practices are using artificial intelligence tools within their patient data environment to identify patients who may benefit from supportive services. Instead of waiting for a busy clinician to remember a referral, systems can flag patients with deteriorating vitals, new metastases or symptom flares. These trigger-based, opt-out models significantly increase utilization of supportive services and do so before a crisis occurs.

Key technologies making this possible include: Natural Language Processing (NLP): Extracts structured data from unstructured sources like scanned consult notes, radiology reports and faxed external records. Machine Learning (ML): Normalizes fragmented patient data across systems, enabling risk stratification and trend detection. Predictive Analytics: Identifies patients at high risk of hospitalization or clinical decline based on multivariate data. EHR-integrated AI Workflows: Automatically suggest palliative consults based on real-time clinical indicators and disease progression markers.

Beyond referrals, forward-looking practices are now building AI-driven dashboards that provide two distinct but complementary functions:

Clinician-Facing Dashboards: These smart dashboards generate a daily patient view tailored to each physician, surfacing insights ahead of every scheduled visit. For example, a dashboard may highlight that a patient’s weight has dropped 8% in two months, pain scores have escalated or home health notes mention caregiver distress. These systems synthesize labs, vitals, patient-reported outcomes and narrative data to equip providers with a whole-patient snapshot, ensuring that supportive needs are addressed during routine follow-ups.

Navigation-Facing Dashboards: These population-level tools enable proactive outreach. By scanning the patient panel, AI can identify individuals not scheduled for visits who nonetheless show signs of decompensation based on rising symptom reports, missed appointments or gaps in follow-up. Navigation teams can then intervene early, scheduling symptom assessments, virtual check-ins or support services. This is especially powerful for patients whose clinical needs fall between routine visits and acute episodes.

In my next post I’ll dive deeper into the application opportunities of AI in oncology. Meanwhile, this table summarizes the broad categories of AI applications being used now:

Together, these systems turn supportive care from a “referral-based” to a “surveillance-based” model: one that detects need before decline and mobilizes the team accordingly. For resource-constrained oncology groups, this technology represents an inflection point: not just smarter data, but smarter care.

📌 Key Takeaways

1. Rename to Reframe: Rebrand services to “Supportive Care” to avoid stigma and encourage earlier adoption.

2. Start with Triggers: Trigger referrals at 2nd-line therapy, new metastases or severe symptom onset to catch patients before crisis.

3. Same-Day Billing Myth: Yes, you can bill advance care planning codes on the same day as a chemo visit. You just need separate documentation.

Final Thought

In 2026, supportive and palliative care are no longer optional. They are foundational. As patients climb the severity ladder, oncology practices must meet them with structure, not improvisation; compassion, not confusion; and strategy, not stigma.

If your organization is designing or expanding supportive, palliative or end-of-life services, I can assist with:

✅ Readiness assessments to evaluate staffing, capacity and feasibility

✅ Financial modeling of supportive care ROI

✅ Workflow design for AI-enhanced, trigger-based referrals

✅ Team training on documentation and goals-of-care conversations

✅ Compliance alignment with OMH, CMS and value-based contracts

Message me at ksvoboda@svobodaconsulting.com to schedule a working session.

References

1. Sanders JJ, Temin S, Ghoshal A, et al. Palliative Care for Patients With Cancer: ASCO Guideline Update. J Clin Oncol. 2024;42(10):1152-1163. doi:10.1200/JCO.24.00542

2. World Health Organization. Palliative care. August 2020. https://www.who.int/news-room/fact-sheets/detail/palliative-care

3. Snaman J, McCarthy S, Wiener L, Wolfe J. Pediatric Palliative Care in Oncology. J Clin Oncol. 2020;38(25):2934-2940. doi:10.1200/JCO.18.02331

4. ASCO. ASCO Certified Patient-Centered Cancer Care Standards: Oncology Medical Home Standards Manual. March 2025. (See Domain F)

5. Alcalde Castro J, Hannon B, Zimmermann C. Integrating Palliative Care into Oncology Care Worldwide. Curr Treat Options Oncol. 2023;24(3):233-245. doi:10.1007/s11864-023-01021-2

6. Wang Y, Feng W. Cancer-related psychosocial challenges. Gen Psychiatry. 2022;35:e100871. doi:10.1136/gpsych-2022-100871