Despite hospices' best efforts to reach those who would benefit from their
end-of-life care, the fact of the matter is most terminally ill people either
never receive hospice care or are admitted too late. Many of those underserved
patients die in hospitals without the benefit of pain management and spiritual
or emotional care.
For years, hospices have conceded that hospitals are a difficult referral
source to tap. Patients either weren't aware of hospice care or clung to the
hope that curative efforts would win out despite the bleakest of prognoses.
Then, as the debate over end-of-life care began to heat up, some hospitals have
begun to realize that their patients would benefit from palliative care, making
their foray into a domain once exclusive to hospices.
As this trend continues, how should hospices react to this movement? Should
it be one of disdain for hospitals that have paid little attention to the
palliative care needs of their patients in the past? Or should hospices embrace
their health care counterparts' newfound enthusiasm for principles hospices
have championed for years?
According to Larry Beresford, a senior writer for the Alexandria, VA-based
National Hospice and Palliative Care Organization (NHPCO) who has been on
special assignment studying hospice and hospital palliative care collaborations,
hospice administrators should see the development of inpatient palliative care
programs as an opportunity to collaborate with their hospital colleagues.
The NHPCO and the New York City-based Center to Advance Palliative Care
(CAPC) have charged Beresford, a former editor of Hospice Management Advisor,
with the task of developing a monograph for that examines hospice-hospital
collaborations in inpatient palliative care. The monograph is due out sometime
In Birmingham, AL, the Birmingham-Area Hospice has been an enthusiastic
supporter of the Balm of Gilead, an inpatient palliative care center inside the
city's Cooper Green Hospital. "Cooper Green was a main referral source to
our hospice," says Gregory Townsend, program director for the
Birmingham-Area Hospice, which is run by the Jefferson County Health Department.
"But we weren't capturing all the patients who could benefit from our
care. The Balm of Gilead helped create a seamless network between the hospital,
hospice, nursing home, and health department."
Hospice input can be essential in the development of a hospital program,
while patient exposure to hospital palliative care can provide patients with
timely and proper information about hospice care that could facilitate more
appropriate hospice admissions.
It was Birmingham-Area Hospice Medical Director Frank Amos Bailey, MD, who
championed the idea of bringing palliative care to patients admitted to Cooper
Green Hospital and helped the hospital secure a three-year, $500,000 grant from
the Robert Wood Johnson Foundation.
"Every palliative care program needs a physician champion," says
Edwina Taylor, CRNP, palliative care specialist with the Balm of Gilead.
Hospices can help hospitals establish palliative care programs that emphasize
the following attributes:
- physical, psychological, social, and spiritual support to help the
patient and family adapt to the anticipated decline associated with advanced,
progressive, incurable disease;
- incorporation of the full array of interinstitutional and community
resources (hospitals, home care, hospice, long-term care, adult day services)
and promotion of a seamless transition between institutions/settings and
- an environment that supports innovation, research, education, and
dissemination of best practices and models of care.
While hospices bring a wealth of palliative care expertise, they need to
cooperate with their hospital partners as they go through the process of
establishing an inpatient palliative care program. To provide direction to
hospitals and hospices, CAPC has outlined this step-by-step approach:
- Identify institutional leaders and initiate a strategic planning process. Strong, effective leadership is unquestionably
the key ingredient for successful development of palliative care programs.
Identify key stakeholders and champions among hospital/health system staff and
from the community.
- Conduct an institutional and community needs assessment for palliative
care services. Developing a new clinical service requires an organized process,
convincing data, and demonstration of a compelling unmet patient need within the
institution as well as the community. Begin this analysis by interviewing
potential stakeholders. Assess their interests and needs. Elicit their support
and identify opportunities for collaboration.
- Survey the community for competitive palliative care services. Evaluate
the following characteristics: length of time in operation; reputation and
ability to meet patient needs; gaps in existing palliative care services;
potential collaborative opportunities.
Provide data on unmet needs
- Profile hospital patient population and demonstrate an unmet patient
need. Profile the patient population that will benefit most from palliative
care. For example, demonstrate the costs to the hospital for failing to
institute appropriate services and discharge options for vulnerable, seriously
ill patients, many of whom are dying. Graphically illustrate the scale of unmet
patient need with data such as:
- total number of hospital deaths annually by age group and insurance
- causes of death by Medicare DRG;
- locations of deaths (eg, medical/surgical unit, ED, ICU, etc.);
- length of stay in hospital and in ICU by DRG among patients who die in
- discharge information (destination);
- number of patients with advance directive, health care proxy, and/or DNR
- Conduct focus groups. Further define your patient population and its
needs by convening several small focus groups to reveal additional reasons for
instituting a palliative care program. Focus groups to convene include
physicians; nurses, social workers, pharmacists, and chaplains; patients in
specific diagnostic groups; and family and caregivers.
- Develop a mission statement, goals, and objectives for the palliative
care program. With your research completed, develop a compelling mission
statement and goals and objectives that reflect and reinforce unmet need.
Establish short-term (12 months) and long-term (three years) program goals that
are as specific and measurable as possible. Goals to consider include:
- patient/caregiver satisfaction;
- physician and staff satisfaction;
- growth in patient volume;
- financial performance;
- impact on length of stay in hospital and ICU;
- Decide on the range of services to offer. The range of palliative care
services offered will depend on variables such as:
- gaps in existing community services;
- type of population to be cared for (e.g., complex tertiary-care referral
populations vs. small community hospital populations of mostly elderly and
- location in the hospital where most patients die;
- inpatient hospital bed constraints.
- Select a delivery model.
- Determine funding sources. Medicare and Medicaid are the primary payers
for palliative and hospice care. Medicare is the benchmark for rates paid by
private insurers for these services.
- Develop a public relations and communications plan. Identify both
internal and external audiences to promote the new service. Activities may
- program brochure and direct mail campaign;
- educational programs for referring physicians, families, and patients;
- local news and human interest stories;
- public relations and fundraising events.
- Develop an operations plan. Identify all the resources/costs required to put the program into operation, including:
- administration and management team;
- community advisory group;
- space renovation and rent;
- capacity (number of beds/patients per staff unit);
- medical and office equipment and supplies;
- medical records;
- quality assurance;
- public relations/communications.
- Develop a financial plan. Using cost estimates from the operations plan,
develop a financial plan including a three-year proposed program budget of
revenues and expenses. Project estimated revenues from all funding sources based
on anticipated patient utilization and service volumes.
- Recruit a skilled interdisciplinary team. Once your program is approved,
it is important to recruit a skilled interdisciplinary team from the outset. For a dedicated
inpatient unit, the team should include a physician, a nurse, a social worker,
and/or a bereavement or pastoral care counselor. If having a dedicated
bereavement staff is not possible, the palliative care service should be able to
refer families to affiliated bereavement program staff. Other experts who can
make a significant contribution to the team include patient advocates,
chaplains, pharmacists, pain experts, rehabilitation experts, and psychiatric
- Develop a patient database to measure quality and outcomes. Clinical
data, patient and family assessments, and financial information should be
collected in easily accessible and usable databases. It is also important to
track and evaluate all program research and educational activities. Data such as
these help quantify the importance of the program and are critical to
demonstrating the program's benefit to the hospital's mission and
Side effect: Timely admissions
How hospitals and hospices work together can vary, says Beresford. Work
arrangements should be dictated by local needs rather than adopting a
In most cases, however, hospices may act simply as consultants to hospital
palliative care programs, providing education and training to hospital staff to
help them recognize candidates for the hospital's palliative care programs.
The Balm of Gilead is a 10-bed dedicated inpatient unit where palliative care
beds are clustered in a specific area of Cooper Green Hospital. This allows the
hospital to concentrate patients with similar needs in one place where
palliative care and consultative services can be provided. Supporters of this
approach say a dedicated unit provides visibility and promotes acceptance of
palliative care as an essential patient care service by hospital staff. As part
of the program, a team composed of doctors and nurses, typically with a social
worker and/or a bereavement counselor, sees patients with palliative care needs.
The Balm of Gilead has contracts with a total of seven hospices in the
Birmingham area in which the hospices provide palliative care services and use
four inpatient hospice beds. As Taylor describes it, the non-territorial
approach of both hospital and hospices has paid off since the Balm of Gilead was
launched in 1998. The program has served more than 700 patients.
Rather than those patients receiving palliative care until their death,
patients who would have died in the hospital actually thrived under care
delivered at the Balm of Gilead. "Less than half of the patients here
actually die on the unit," says Taylor.
That meant more patients were coming home and were in need of care. The
increased awareness of hospice care as a result of inpatient palliative care
increased the number of hospice admissions. The Birmingham-Area Hospice went
from an average daily census of 25 patients in 1998 to 63 patients today, says
"We have been able to meet the needs of patients not quite ready for
hospice care and have been able to get them into hospice care when they were
ready," Townsend says.
This story originally appeared in Hospice Management Advisor, published by
American Health Consultants. (800) 688-2421.