Summary
Through 25 KodaCares calls spanning five phases of illness, Koda's patient advocate navigated hospitalizations, condition changes, and difficult conversations — ensuring this HMCC patient reached hospice with her goals documented, her family informed, and her wishes honored.
Koda Cares · Patient Case Study
A Patient’s Journey: Goals of Care to Hospice
Pulmonary FibrosisSclerodermaRaynaud’sComplex multi-system illness with sustained Koda advocacy
| 25Total Touchpoints | 14+Months of Engagement | 6+Providers Coordinated | 4Hospitalizations | 3 Months on HospiceFinal Outcome |
| 🌿 |
14 months of advocacy. One patient’s dignity protected.
Through 25 KodaCares calls spanning five phases of illness, Koda’s patient advocate navigated hospitalizations, condition changes, and difficult conversations — ensuring this HMCC patient reached hospice with her goals documented, her family informed, and her wishes honored.
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Goals of CareSymptom MgmtPalliative TransitionComfort-FocusedHospice
| Goals of Care & Advance Directive | Symptom Management & Coordination | Palliative Care Transition | Comfort-Focused Decision Making | Hospice Enrollment & Support |
| Phase 1 · Goals of Care & Advance Directive | Feb – May 2024 |
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Initial KodaCares Call
ACP CompletedGoals Explored
View call notesIntroductory KodaCares call. Patient’s goals of care explored and advance care plan completed and documented during this initial engagement.
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Call 2: Functional Decline Noted
Emotional SupportPalliative IntroDME Requested
View call notesPatient reported increasing functional decline. Palliative care introduced as a supportive option and durable medical equipment requested to support daily function. Emotional support provided.
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| Phase 2 · Symptom Management & Coordination | May – Sep 2024 |
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Call 3: ACP Signed & Pain Escalation Noted
Morphine StartedACP SignedReferral Made
View call notesAdvance care plan formally signed — a key milestone. Pain escalation noted and morphine initiated for symptom management. Referral made to appropriate support services.
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Call 4: Pneumonia Diagnosis & Case Manager Follow Up
PNA DiagnosedCase Manager Follow Up
View call notesPatient diagnosed with pneumonia. Follow-up coordinated with case manager to ensure continuity of care and monitoring.
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Call 5: PNA Follow-Up & GI Symptoms
Symptom ManagementCase Manager Follow Up
View call notesFollow-up on pneumonia recovery; new gastrointestinal symptoms reported and addressed. Continued coordination with case manager on symptom management plan.
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Call 6: Increased ADL Need
ADL SupportDME PursuedHome Care Coordination
View call notesIncreased need for assistance with activities of daily living identified. Additional durable medical equipment pursued and home care coordination initiated.
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Call 7: Bronchoscopy Needed; Palliative Discussed
Palliative DiscussedDME Discussed
View call notesBronchoscopy identified as a needed next step. Palliative care options discussed further with patient, along with continued durable medical equipment needs.
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Call 8: Hospitalization — Lung Infection (4 days)
HospitalizedPICC Line
View call notesPatient hospitalized for 4 days due to lung infection. PICC line placed during admission for ongoing treatment.
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Call 9: ADL Support Navigation
ADL Support
View call notesContinued navigation of support for activities of daily living following recent hospitalization.
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Call 10: Fall at Home
FallSafety Concern
View call notesPatient experienced a fall at home. Safety concerns discussed and addressed with the care team.
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Call 11: Wrist MRI; Increasing Leg Heaviness
Functional Decline
View call notesWrist MRI conducted following fall. Patient reported increasing heaviness in legs, indicating continued functional decline.
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| Phase 3 · Palliative Care Transition | Oct 2024 – Feb 2025 |
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Call 12: ER Visit; Insurance Navigation
ER VisitInsurance Navigation
View call notesPatient had an emergency room visit. Koda assisted with insurance navigation to support continued access to care.
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Call 13: DME & Palliative Referral Re-Initiated
DME RequestedPalliative Referral
View call notesDurable medical equipment request renewed. Palliative care referral re-initiated to ensure continuity of supportive services.
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Call 14: Hospitalization — PNA (4th Admission)
HospitalizedACP Upload Needed
View call notesFourth hospital admission, related to pneumonia. Advance care plan identified as needing upload to the patient’s medical record for care team visibility.
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Call 15: Discharge; Palliative Order Initiated
DischargedPalliative Order
View call notesPatient discharged from hospital. Order for palliative care services initiated as part of discharge planning.
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Call 16: Palliative Provider Engaged
Palliative Active
View call notesPalliative care provider engaged and services now active for the patient.
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Call 17: DME Advocacy
Escalated Advocacy
View call notesDurable medical equipment request escalated. Koda advocated on the patient’s behalf to move the request forward.
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Call 18: Palliative Order Still Not Received
Persistent Coordination
View call notesPalliative order remained outstanding. Koda continued persistent coordination with providers to resolve the delay.
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Call 19: ✅ Palliative Visit Achieved
Milestone Reached
View call notesPalliative care visit finally achieved after sustained advocacy — a key milestone in the patient’s care plan.
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| Phase 4 · Comfort-Focused Decision Making | Feb – Mar 2025 |
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Call 20: DNR Conversation & Plan Update
DNR UpdatedOOH-DNRHospice Consult PlannedEmotional Support
View call notesDo-not-resuscitate conversation held and care plan updated accordingly. Out-of-hospital DNR discussed. Hospice consult planned. Emotional support provided throughout.
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Call 21: ✅ AD & OOH-DNR Signed
AD SignedOOH-DNR Signed
View call notesAdvance directive and out-of-hospital DNR formally signed — a significant milestone in documenting the patient’s comfort-focused wishes.
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Call 22: Hospice Consult with Family Present
Family MeetingHospice Consult
View call notesHospice consult conducted with family present, ensuring shared understanding of the patient’s care trajectory and options.
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Call 23: Processing Hospice Decision
Emotional SupportDecision Support
View call notesPatient and family continued processing the decision to move toward hospice care. Emotional and decision support provided.
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| Phase 5 · Hospice Enrollment & Support | Apr – May 2025 |
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Call 24: ✅ Hospice Enrollment
Hospice Enrolled
View call notesPatient officially enrolled in hospice care, completing the transition to comfort-focused, goal-aligned care.
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| 25Total Touchpoints | 14+Months of Engagement | 6+Providers Coordinated | 4Hospitalizations | 3 Months on HospiceFinal Outcome |
| 🌿 |
14 months of advocacy. One patient’s dignity protected.
Through 25 KodaCares calls spanning five phases of illness, Koda’s patient advocate navigated hospitalizations, condition changes, and difficult conversations — ensuring this HMCC patient reached hospice with her goals documented, her family informed, and her wishes honored.
|
Goals of CareSymptom MgmtPalliative TransitionComfort-FocusedHospice
| Goals of Care & Advance Directive | Symptom Management & Coordination | Palliative Care Transition | Comfort-Focused Decision Making | Hospice Enrollment & Support |
| Phase 1 · Goals of Care & Advance Directive | Feb – May 2024 |
|
Initial KodaCares Call
ACP CompletedGoals Explored
View call notesIntroductory KodaCares call. Patient’s goals of care explored and advance care plan completed and documented during this initial engagement.
|
|
Call 2: Functional Decline Noted
Emotional SupportPalliative IntroDME Requested
View call notesPatient reported increasing functional decline. Palliative care introduced as a supportive option and durable medical equipment requested to support daily function. Emotional support provided.
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| Phase 2 · Symptom Management & Coordination | May – Sep 2024 |
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Call 3: ACP Signed & Pain Escalation Noted
Morphine StartedACP SignedReferral Made
View call notesAdvance care plan formally signed — a key milestone. Pain escalation noted and morphine initiated for symptom management. Referral made to appropriate support services.
|
|
Call 4: Pneumonia Diagnosis & Case Manager Follow Up
PNA DiagnosedCase Manager Follow Up
View call notesPatient diagnosed with pneumonia. Follow-up coordinated with case manager to ensure continuity of care and monitoring.
|
|
Call 5: PNA Follow-Up & GI Symptoms
Symptom ManagementCase Manager Follow Up
View call notesFollow-up on pneumonia recovery; new gastrointestinal symptoms reported and addressed. Continued coordination with case manager on symptom management plan.
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Call 6: Increased ADL Need
ADL SupportDME PursuedHome Care Coordination
View call notesIncreased need for assistance with activities of daily living identified. Additional durable medical equipment pursued and home care coordination initiated.
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Call 7: Bronchoscopy Needed; Palliative Discussed
Palliative DiscussedDME Discussed
View call notesBronchoscopy identified as a needed next step. Palliative care options discussed further with patient, along with continued durable medical equipment needs.
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Call 8: Hospitalization — Lung Infection (4 days)
HospitalizedPICC Line
View call notesPatient hospitalized for 4 days due to lung infection. PICC line placed during admission for ongoing treatment.
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Call 9: ADL Support Navigation
ADL Support
View call notesContinued navigation of support for activities of daily living following recent hospitalization.
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Call 10: Fall at Home
FallSafety Concern
View call notesPatient experienced a fall at home. Safety concerns discussed and addressed with the care team.
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Call 11: Wrist MRI; Increasing Leg Heaviness
Functional Decline
View call notesWrist MRI conducted following fall. Patient reported increasing heaviness in legs, indicating continued functional decline.
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| Phase 3 · Palliative Care Transition | Oct 2024 – Feb 2025 |
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Call 12: ER Visit; Insurance Navigation
ER VisitInsurance Navigation
View call notesPatient had an emergency room visit. Koda assisted with insurance navigation to support continued access to care.
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Call 13: DME & Palliative Referral Re-Initiated
DME RequestedPalliative Referral
View call notesDurable medical equipment request renewed. Palliative care referral re-initiated to ensure continuity of supportive services.
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Call 14: Hospitalization — PNA (4th Admission)
HospitalizedACP Upload Needed
View call notesFourth hospital admission, related to pneumonia. Advance care plan identified as needing upload to the patient’s medical record for care team visibility.
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Call 15: Discharge; Palliative Order Initiated
DischargedPalliative Order
View call notesPatient discharged from hospital. Order for palliative care services initiated as part of discharge planning.
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Call 16: Palliative Provider Engaged
Palliative Active
View call notesPalliative care provider engaged and services now active for the patient.
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Call 17: DME Advocacy
Escalated Advocacy
View call notesDurable medical equipment request escalated. Koda advocated on the patient’s behalf to move the request forward.
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Call 18: Palliative Order Still Not Received
Persistent Coordination
View call notesPalliative order remained outstanding. Koda continued persistent coordination with providers to resolve the delay.
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Call 19: ✅ Palliative Visit Achieved
Milestone Reached
View call notesPalliative care visit finally achieved after sustained advocacy — a key milestone in the patient’s care plan.
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| Phase 4 · Comfort-Focused Decision Making | Feb – Mar 2025 |
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Call 20: DNR Conversation & Plan Update
DNR UpdatedOOH-DNRHospice Consult PlannedEmotional Support
View call notesDo-not-resuscitate conversation held and care plan updated accordingly. Out-of-hospital DNR discussed. Hospice consult planned. Emotional support provided throughout.
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Call 21: ✅ AD & OOH-DNR Signed
AD SignedOOH-DNR Signed
View call notesAdvance directive and out-of-hospital DNR formally signed — a significant milestone in documenting the patient’s comfort-focused wishes.
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Call 22: Hospice Consult with Family Present
Family MeetingHospice Consult
View call notesHospice consult conducted with family present, ensuring shared understanding of the patient’s care trajectory and options.
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Call 23: Processing Hospice Decision
Emotional SupportDecision Support
View call notesPatient and family continued processing the decision to move toward hospice care. Emotional and decision support provided.
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| Phase 5 · Hospice Enrollment & Support | Apr – May 2025 |
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Call 24: ✅ Hospice Enrollment
Hospice Enrolled
View call notesPatient officially enrolled in hospice care, completing the transition to comfort-focused, goal-aligned care.
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Call 25: Continued Check-In & Emotional Support
Emotional SupportOngoing Presence
View call notesContinued check-in call. Emotional support provided and ongoing Koda presence maintained throughout the patient’s time on hospice.
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3 Months on Hospice
Final Outcome
14 months of sustained advocacy across 25 touchpoints and 5 phases of illness · Goals documented · Family informed · Wishes honored
KodaCares is the human layer that supports goal-concordant care
Most advance care planning tools stop at the document. A form gets filled out, a PDF gets signed, and it sits in a chart until someone remembers to look for it.
KodaCares is built around a different idea: a signed form isn’t the finish line, it’s the starting point. It’s Koda’s human escalation layer: a team of dedicated patient advocates who stay engaged with patients over time, not just at a single point of documentation. When a patient’s condition changes, when a new symptom shows up, when a hospitalization happens, or when a family starts asking hard questions, there’s already someone who knows the patient’s history on the other end of the line.
That’s the part that’s easy to describe and hard to build: continuity. Not a call center. Not a one-and-done intake script. The same kind of ongoing relationship a care manager builds, but focused specifically on goals of care, and available for as long as the patient needs it.
Why longitudinal matters more than the first conversation
A single goals-of-care conversation is a snapshot. It captures what a patient wants on the day it happens. But serious illness rarely moves in a straight line, it moves in phases, and what a patient wants often shifts as their condition does. Someone who wanted “everything done” at diagnosis may feel very differently after a fourth hospitalization.
The patient journey below is a real example of what that looks like when it’s tracked over time rather than checked off once:
- 25 touchpoints across 14+ months
- 6+ providers coordinated along the way
- 4 hospitalizations
- A final outcome of 3 months on hospice, reached with the patient’s goals documented, her family informed, and her wishes honored
That’s not 25 identical calls. It’s a relationship that moved through five distinct phases: from an initial goals-of-care conversation, through symptom management and repeated care coordination, into a palliative care transition that took months of persistent advocacy to actually land, then into comfort-focused decision-making, and finally into hospice enrollment and ongoing support even after the decision was made.
Look closely at the timeline and a pattern shows up again and again: a referral gets made, but doesn’t happen on the first try. A palliative order gets requested in November and isn’t fulfilled until February. An advocate follows up, escalates, follows up again. None of that shows up in a single ACP document. It only shows up when someone is actually staying with the case.
What this looks like day to day
In practice, KodaCares advocacy shows up as things like:
- Checking in after a hospitalization, not waiting for the next scheduled visit
- Noticing functional decline early and introducing palliative care as an option before a crisis forces the conversation
- Re-initiating referrals and equipment requests that stall in the system
- Holding space for the emotional weight of a DNR conversation or a hospice decision, for the patient and the family both
- Making sure the advance care plan is actually visible to the care team when it matters: not just signed, but uploaded, findable, and used
None of it depends on the patient or family knowing what to ask for next. That’s the advocate’s job.
The takeaway
A signed advance directive tells you what a patient wanted on one day. A sustained KodaCares relationship tells you what a patient’s care team actually did about it, month after month, as things changed. That distinction, a document versus a conversation that keeps going, is the difference this timeline is meant to show.
Client Feedback
I really appreciated that there was no pressure or deadline, I could take my time. Some of the questions were detailed and emotional, and I needed a few minutes to think before answering. Knowing there was someone I could call and talk to made all the difference. And the fact that it was free was such a relief. I was so grateful for the guidance that I ended up enrolling my husband too.
Houston Methodist Patient
