It has happened hundreds of times: I’m called into the ICU as a Palliative Care specialist, ask who the patient is and what matters most, and afterward a family member pulls me aside to say, “No one has ever had this conversation with us before. I wish someone had done this sooner. Thank you.”
That moment is meaningful, but it is also hard to hear. Too often, Palliative Care is still confused with hospice or end-of-life care. As a result, consults come too late, if at all, and teams miss earlier chances to address the physical, emotional, psychological, and spiritual distress that often comes with serious progressive illness. For older adults with medical complexity, the current model frequently waits until crisis before offering the kind of proactive, whole-person support that we would all want for ourselves and our own families.
That is the challenge Monogram Health is tackling: expanding the perceived benefit of Palliative Care that historically has been seen as “helping people die well” to becoming much more about enabling people to live as well as possible with serious illness. The mission is to reduce avoidable suffering, clarify what matters most, and help patients make care decisions that fit their lives. To do that, we need to shift from seeing an individual who has a specific illness, to seeing the whole person who is living with multiple chronic illnesses.
Ever since its inception, Palliative Care has had to struggle with the limited way that it can show financial value in the fee-for-service ecosystem. Much like a plant finally planted in a nutrient rich soil, Palliative Care can thrive in a value-based model, where success depends on better medical, functional, emotional, and social outcomes—not just more encounters.
The Monogram Difference
At Monogram, we have broadened Palliative Care into a practical, holistic model focused on quality of life. Our framework brings together the National Consensus Project’s eight domains of Palliative Care with core principles learned from Geriatric medicine.
These principles are built into Monogram’s core model and delivered by Monogram physicians, nurse practitioners, nurses, and social workers that can also work alongside patient’s established community care teams (PCPs, specialists, etc.) if applicable. As patients become more complex, we layer in deeper Palliative and Geriatric assessments and bring in our specialty Palliative Care team—board-certified Palliative medicine physicians, advanced practice providers, nurses, and chaplains—as longitudinal, integrated partners rather than one-time consultants.
In practice, every Monogram patient—whether they are living with diabetes, hypertension, chronic kidney disease, heart failure, COPD, or another chronic illness—receives comprehensive assessments to identify where more support is needed. As disease progresses, those assessments deepen to include not only medical needs, but also symptoms, function, family support, social needs, and spiritual concerns. This allows us to identify risk and suffering earlier than traditional care models often can, while also enabling us to engage in more dynamic advance care planning discussions.
Because Monogram brings care into the home, our teams see what clinic and hospital settings often miss: the neighborhood, the living environment, caregiver dynamics, and daily routines. Those details make care personal. A conversation about the importance of spending time with grandchildren evolves into holding a crayon drawing with “NANA” that was sitting prominently on the coffee table. A discussion about how a patient’s Parkinson’s disease is impacting their passion for woodworking carries more weight when the team is actually sitting on furniture the patient built years earlier.
For patients earlier in the disease course but still at high risk for declining quality of life, this approach turns technical conversations about A1c, blood pressure, or kidney function into personal discussions about maintaining independence and preserving meaningful activities by reducing the risk of strokes, avoiding ESRD and the real-world difficulties with renal replacement therapy. For patients facing shorter prognoses or major decisions, it provides the context needed for serious illness conversations and goal-concordant care that are hallmarks of specialty Palliative Care.
Reframing Upstream
Studies and real-world outcomes have shown that earlier involvement of Palliative Care increases the overall impact, but there is limited consensus on what that care looks like since upstream Palliative Care is not realistic in fee-for-service settings. A key focus at Monogram involves integrating best practice Geriatric principles into the Palliative Care program since our population represents a multimorbid Geriatric population that has little to no previous access to both specialty Palliative Care (outside of the inpatient settings) and comprehensive interdisciplinary Geriatric practices. Blurring the lines of Geriatrics and Palliative Care is a controversial topic that requires nuance, yet organizations that weave both Geriatric and Palliative Care approaches into the DNA of the model are best positioned to face the “silver tsunami” that has already arrived.
Below are four ways that Monogram is leading the way:
- New Paradigm: We combine the Geriatrics “Five M’s”—mobility, multi-complexity, matters most, mind, and medications—with the National Consensus Project’s eight domains of Palliative Care.
- New Interventions: Monogram’s core model already includes functional status, fall risk, cognition, polypharmacy, urinary incontinence, vision and hearing screens, advance care planning, and Palliative assessments. We are strengthening that foundation with more robust dementia support, falls education and prevention, and high-risk medication monitoring.
- More Integration: Our Advanced Supportive and Palliative Care program addresses symptom burden, quality of life, and goal alignment through specialist-led in-home and virtual support. The specialty interdisciplinary team works alongside each patient’s Monogram team and established community clinicians.
- Holistic Support delivered by an interdisciplinary team: Our teams are also trained to think beyond the typical categories in hospitals and clinics. One recent patient was dealing with heart failure and frequent falls. The hospital team was most concerned about the patient’s limited home support that could lead to another fall, yet she remained adamant about living at home. This is a common issue older patients with increased frailty experience, but thinking holistically about this patient unearthed that her desire to stay at home was related to unresolved trauma from a family member recently dying at a nursing home in addition to having a strong spiritual call to remain at the home in which her and her husband ran an informal ministry for decades. The limited family support was due to strained relationships that a frank conversation about a limited prognosis would force the family to address these issues and rally around a loved one in times of greatest need. What at the surface level appeared to be the typical scenario of a patient needing more caregiving support, became an opportunity for the chaplain to address existential and spiritual distress of the patient and their family. This unearthed background and understanding opened a door for a licensed clinical social worker to tackle the complex web of family systems that make each family unique, and it empowered the physician to have a frank discussion about the prognosis with the family – who ended up putting aside past differences to make the most of limited time.
Outcomes
Proactive, upstream Palliative Care can also reduce utilization and cost. Over the last year (2025), Monogram completed 996 hospice evidence-based clinical interventions, representing an estimated $16.4 million in savings, as well as 154 evidence-based Palliative clinical interventions, representing an estimated $1.4 million in savings. As we continue to redesign the Palliative clinical intervention pathway, we expect this impact to grow.
Patients nearing the end of life often prefer comfort-focused care and to die at home, yet only about 30% do. That gap creates a real burden for patients, families, clinicians, and health systems. Monogram Health recently launched a system to measure symptom burden, which will also help us better understand caregiver burden, patient and family experience, and the behavioral health impact of serious illness.
The larger opportunity is to make Palliative Care proactive, practical, and scalable. By embedding Palliative and Geriatric principles into the core care model—and reserving specialty Palliative expertise for the patients and families who need it most—Monogram is building a model that is both clinically personal and operationally sustainable.
Attributed to: Alan Chiu, M.D., Chief of Palliative Care at Monogram Health
This article was published on Beckers Hospital Review on June 17, 2026.
