November 5, 2026
Virtual Community Palliative Care as a Population Health Strategy
By Kurt Merkelz, MD, FAAHPM
Demand for palliative care is expected to rise as the population ages, with nearly three-quarters of palliative care professionals already reporting an increase in consult volumes since last year.1 Despite the increased demand, recent data from the Center to Advance Palliative Care shows access gaps remain, particularly in more rural settings.2 As providers adapt to meet patient needs, applying population health principles to virtual community palliative care can improve outcomes while helping patients remain safely at home or in their preferred living environment.
Shifting the Focus from Process to Outcomes
The 30-day readmission rate remains a top concern for hospitals and health systems as it is tied to reimbursement, star ratings, and network performance, among other metrics. Advanced illness populations disproportionately drive utilization and fragmented transitions between points of care can result in unnecessary readmissions. The current health system relies heavily on outpatient referrals to complete treatment of isolated needs, which can often miss the bigger, more complex picture of care for frail, multi-chronic, and older adults.
Applying population health principles to virtual community palliative care allows providers to address some of these care continuity challenges and empower patients and caregivers with tools and frameworks that promote autonomy, improve quality of life, and mitigate undesirable outcomes.
Population Health Management and Palliative Care: Powerful Synergy
Technology-enabled, patient-centered community palliative care supports integrated care that eliminates silos and addresses access challenges, driving patients to stabilize and return to living successfully—whatever that looks like for the patient in their preferred environment.
While most seriously ill people want to stay at home, nearly 20% of Medicare patients are re-hospitalized within 30 days, and many of those hospitalizations are preventable.3 Integrating virtual visits into community palliative care is a novel approach to enhance patient outcomes using comprehensive medication management, home safety, and caregiver burden assessments to address population health goals.
Moving from Reactive to Proactive: Risk Prediction Framework
When palliative care is provided in the home, long-term care, or nursing facility, providers have a unique opportunity to assess and screen for preventable hospital readmission risks such as medication adherence, environmental safety, and caregiver strain. Virtual visits offer increased touchpoints for patients and providers, and technology such as remote patient monitoring, predictive analytics, and caregiver engagement tools provide the data and structured assessments necessary to evaluate risk, even when not physically present with the patient.
Incorporating a risk prediction framework specifically for palliative populations can aid providers not only in identifying the likelihood of potential health events but also in administering preventive measures to improve quality of life and reduce safety risks. The data gathered by remote patient monitoring equipment such as pulse oximeters, connected scales, digital thermometers, blood pressure monitors, and more, can offer a fairly comprehensive picture of the patient’s condition in between physical visits. AI-triggered alerts can notify providers of potential symptom escalation. For patients in rural areas or with limited access to providers, these tools can be transformative.
Incorporating Virtual Tools to Support Transitional Care Excellence
Patient and caregiver engagement is a key factor in the success of technology-based support for care transitions. In virtual community palliative care, providers leverage technology and population health tools to conduct virtual palliative care visits with the goal of reducing preventable readmissions, improving symptom management, increasing patient satisfaction, and enhancing caregiver resilience.
By initiating the approach prior to discharge from the hospital or inpatient skilled nursing facility, patients and their caregivers understand how virtual visits will be used to supplement in-person check-ins, better preparing them to collaborate more effectively during care planning.
One example of how virtual visits can help prevent symptom crises is by supporting the medication reconciliation process. One-third of hospice providers report frequently encountering problems with caregivers managing medications, highlighting an opportunity for technology-enabled care to provide ongoing support between in-person visits.4 Remote patient monitoring tools can track health changes potentially caused by medication misuse and offer providers real-time insights. Virtual visits also offer opportunities to check in with the patient and caregiver to discuss and review the medication management system and adherence. When caregivers and patients feel supported, it relieves the burden of care variables that can have health-outcome implications for the patient.
Empowering Patients, Caregivers, and Providers: The Key to Improving Outcomes and Quality of Life Goals
The greatest impact of leveraging technology for community palliative care may be the ability to provide patients and caregivers with tools that empower them to live successfully in their preferred living environment. Recent studies show technology can enhance quality of life and the efficiency of palliative care by reducing hospital visits and caregiver stress and improving patient-provider communication.5 This requires a shift in how we think about a patient’s care journey and the outcome of their care. While younger populations and those with acute serious illnesses may become cured or achieve a new stability of their condition, the elderly and those with more complex conditions may not enjoy the same outcome. In these cases, virtually aided community palliative care can be instrumental in helping someone live autonomously with tools at their disposal that support their quality-of-life goals.
The technology is here to allow us to work smarter and better for our patients— and it continues to improve rapidly, opening the door for ongoing innovation and transformation in palliative care and the patient healthcare journey overall. Palliative care providers can leverage these tools efficiently to improve patient outcomes and experiences and to extend the availability and access to this care to more populations who could greatly benefit from it.
Working with other providers and partners to educate them about the benefits of virtual community palliative care strategies for advancing population health goals could have a meaningful impact on our ability to care for more patients in their homes, mitigate undesirable outcomes, and enhance outcomes and satisfaction.
Kurt Merkelz is senior vice president and chief medical officer of Compassus, a leading national provider of integrated home-based care, including home health, infusion therapy, palliative care, home care, and hospice. He is triple board-certified in hospice and palliative care medicine, family practice, and geriatrics.
References
1. Heitner R. The results are in: Palliative care professionals share how they’re doing in 2025. Center to Advance Palliative Care (CAPC) December 16, 2025. https://www.capc.org/blog/the-results-are-in-palliative-care-professionals-share-how-theyre-doing-in-2025/
2. America’s Readiness to Meet the Needs of People with Serious Illness: 2024 Serious Illness Scorecard. Center to Advance Palliative Care. August 2024. https://scorecard.capc.org/findings/
3. Readmissions and Adverse Events After Discharge. Agency for Healthcare Research and Quality (AHRQ) PSNet. June 15, 2024. https://psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge
4. Joyce BT, Lau DT. Hospice experiences and approaches to support and assess family caregivers in managing medications for home hospice patients: a providers survey. Palliat Med. 2013;27(4):329-338. doi: 10.1177/0269216312465650
5. Maguraushe K, Ndlovu BM. The use of smart technologies for enhancing palliative care: A systematic review. Palliative Medicine in Practice. October 29, 2024. https://journals.sagepub.com/doi/10.1177/20552076241271835