Leadership
Needs Assessment
Writing A Business Plan
Reimbursement
Delivery Models
Inter-Disciplinary Team
Program Operations
Quality Assessment







A Palliative Care Continuum: Palliative CareCenter & Hospice of the North Shore

Palliative CareCenter & Hospice of the North Shore has assembled a hospice-based continuum of palliative care services that includes hospice care, home health care, private duty caregivers, case management and palliative care consultation.
November 2001

Untitled

Evanston/Skokie, Illinois

Summary: In Evanston, a near-northern suburb of Chicago, IL, Palliative CareCenter & Hospice of the North Shore has assembled a hospice-based continuum of palliative care services that includes hospice care, home health care, private-duty caregivers, case management and palliative care consultation. A cornerstone of its continuum is a hospice inpatient unit operated by the agency in leased space on the campus of Rush North Shore Medical Center in neighboring Skokie. Collaboration between independent, community-based Palliative CareCenter & Hospice of the North Shore and the hospital, part of Rush System for Health, centers on the successful inpatient unit but holds the potential for a variety of future partnerships.

SETTING

            In the highly competitive metropolitan Chicago healthcare market, there are more than 30 competing hospice providers, and a wave of hospital mergers has created six major hospital systems. One of those is Rush System for Health, based at Rush-Presbyterian-St. Luke’s Medical Center, the largest private hospital in Illinois. Rush System for Health has a number of health divisions and hospital partners, including since 1987 Rush North Shore Medical Center (RNSMC) in Skokie. The Rush system has its own hospice program, Rush Hospice Partners, assembled through mergers by its hospitals. But despite its corporate affiliation with the huge tertiary medical center, 268-bed RNSMC operates in many ways like a community hospital. The hospital enjoys a collaborative relationship with independent Palliative CareCenter & Hospice of the North Shore (PCCHNS) located nearby in Evanston.

PCCHNS was founded in 1978 as a volunteer hospice and granted Medicare certification in 1989. In 1990, it was serving an average daily census of five patients, but it has since grown into a multi-faceted organization that serves an estimated 2,000 patients per year from its various programs, plus another 1,500 families receiving bereavement support. PCCHNS has an annual budget of $11 million; its hospice program carries an average daily census of 165 patients.

In 1995, the community-based, non-profit organization changed its name from Hospice of the North Shore to Palliative CareCenter – and, more recently, to Palliative CareCenter & Hospice of the North Shore. The changes were made with deliberate intent to establish a broader continuum of palliative care services from the point of diagnosis for patients and families confronting serious, life-challenging or life-threatening illnesses. Within that continuum, the licensed, certified hospice division has a key role as the provider of intensive, end-stage care. Currently, in addition to its hospice and associated bereavement program, PCCHNS offers the following components:

Ø       A licensed, JCAHO-accredited home health agency, which has been somewhat constrained recently by implementation of Medicare’s home health prospective payment system.

Ø       A joint venture, through a for-profit subsidiary, with a private duty home care service called Respite Care, Inc., providing home caregiving staff on a private-pay basis.

Ø       A comprehensive pediatric hospice and palliative care program in collaboration with Children’s Memorial Hospital, which includes a contract for inpatient beds at the hospital.

Ø       A kid’s bereavement camp and other specialized pediatric services.

Ø       A community outreach program staffed by a registered nurse providing no-cost, phone-based care management services to clients who otherwise might fall through the cracks of reimbursed healthcare services.

Ø       A physician-led palliative care consultation team that operates in hospitals, nursing homes and an outpatient clinic – but primarily in patients’ homes – at the request of attending physicians, billing Medicare and other payers for its consults.

Ø       A 15-bed hospice inpatient unit, operated in leased space on the campus of RNSMC.

Ø       Physicians and nurse practitioners provide homebound adults with primary care, comprehensive evaluation, diagnostic testing, and treatment of acute and chronic illnesses through a Medical Home Visits program.

 PCCHNS has contracts with 12 area hospitals, primarily to obtain acute care beds on a scatter-bed basis for its hospice patients in need of general inpatient care. Generally, those referrals follow the hospital affiliation of the patient’s attending physician. PCCHNS also contracts with 70 long-term care facilities to provide hospice care to terminally ill residents of those facilities. The hospice has a full-time medical director and nine part-time assistant medical directors. PCCHNS’ continuum of services is tied together by an agency philosophy of directing patients who are confronting life-threatening or life-limiting illnesses to the most appropriate setting for their care and then billing for the reimbursement that is available to pay for the care. 

WHAT IS THE PROGRAM

A)            Hospice Inpatient Unit: In July of 1999, RNSMC and PCCHNS opened a collaborative, 15-bed hospice inpatient unit on RNSMC’s hospital campus. The origins of this partnership lay in a previous collaboration between PCCHNS and Evanston Hospital, part of the Evanston Northwestern HealthCare system. Starting in 1995, PCCHNS had leased space from Evanston Hospital to operate a 12-bed hospice unit in the hospital. In 1999, Evanston Hospital opted to reclaim its beds for acute care expansion plans, so PCCHNS had to quickly relocate its inpatient unit. The original unit contract with Evanston Hospital had been painstakingly negotiated over a two-year period. Based on that experience, PCCHNS was able to work out all of the details of reestablishing a unit at RNSMC within eight weeks.

As at Evanston Hospital, RNSMC’s acute care beds are mostly full. However, RNSMC had unoccupied space to offer in an adjacent building that was also home to medical offices and a psychiatric treatment facility. PCCHNS and RNSMC shared the expense of refurbishing and converting the floor to a homelike atmosphere. Evanston Hospital and the community also made significant charitable contributions.

The 15-bed hospice unit, currently operating within licensed psychiatric beds, is intended for terminally ill, hospice-appropriate patients. Occupancy on the unit is running more than 80 percent, with frequent waiting lists. The unit admits RNSMC patients who are transferred directly from the hospital at the time they enroll in hospice, patients enrolled in PCCHNS’ hospice program who need inpatient care and patients from other local hospices and hospitals, subject to the approval of PCCHNS’ hospice medical director. Average length of stay on the hospice unit is nine days, and half of admitted patients die there. The unit, which has numerous homelike amenities, includes clinic space for palliative care consults and is also used for community bereavement and patient support groups. 

B)            Palliative Care Continuum: Staff of PCCHNS emphasizes that by adopting a palliative care philosophy they are not using the term as a substitute or euphemism for hospice care. Palliative care is defined as interdisciplinary care that aims to relieve suffering and improve quality of life at any age, at any stage and in any setting from the point of diagnosis of a life-threatening illness through the end of life and bereavement. While hospice care has a crucial place in the care continuum as the most intensive form of palliative care, palliative support may be needed by patients much earlier in the progression of a life-threatening illness.

Other services are designed to plug specific holes in care delivery, with the aim of meeting more of the needs experienced by patients confronting life-threatening illnesses. Each component operates and receives reimbursement within its own regulatory structure. Within those limits, PCCHNS has attempted to provide a care continuum that is broad enough to meet the palliative care needs of most seriously ill patients.

Palliative care, under PCCHNS’ reorganized structure, is the umbrella concept for its service continuum. Access to consultations by the core interdisciplinary palliative care team is the glue that holds the discrete services together – with the team reevaluating patients’ needs and helping to direct them to the most appropriate setting and service to meet their needs. The various programs operate as separate divisions, but with a shared admission department and close inter-departmental communication to achieve a more seamless, integrated continuum of care. 

EXPERIENCE OF COLLABORATION

When PCCHNS approached RNSMC administrators in 1999 to explore its urgent need for new inpatient space, the timing was fortuitous, since the hospital had unoccupied licensed psychiatric hospital beds and was considering whether to return the bed licenses to the state. The hospital’s president met with his senior management team to determine if there was a consensus for collaborating with PCCHNS on a leased hospice unit. Having reached a consensus, the institution committed itself to working out details of the transition as quickly as possible. RNSMC contributed more than $300,000 in financial and in-kind support toward opening the hospice unit. With hospital space at a premium and other departments having space needs of their own, making 10,000 square feet available to PCCHNS demonstrated a genuine commitment to the collaboration by RNSMC. Another sign of that institutional commitment is the respective partners’ ability to quickly resolve problems when they arise.

Previously, the hospital had established a task force to explore palliative care development on its own, and members of that task force visited other hospice and palliative care units. Ultimately, RNSMC concluded that it would be easier, less costly and more “professional” to work with an established hospice/palliative care partner, rather than trying to create the expertise from within. Already, according to the hospital’s chair of internal medicine, there are signs that physicians within the hospital are observing and learning from the palliative medicine practiced by PCCHNS on its hospice inpatient unit, for example, in terms of drugs and dosages used for managing symptoms.

The hospital also reports that in the year following the simultaneous openings of the hospice unit and a skilled nursing unit on its campus, overall length of stay for all hospitalized patients went down one-half day. In a context of limited acute care beds, having the hospice unit nearby provides an outlet for transferring terminally ill patients who may be imminently dying but are not candidates for discharge. PCCHNS also collaborates with the hospital’s pain center.

Despite the stresses of having to move its inpatient unit at short notice, PCCHNS has maintained good relations with Evanston Hospital. Referrals to PCCHNS’ hospice unit at RNSMC come from Evanston Hospital’s physicians and its hospice program, from Rush Hospice Partners for its patients who live in the North Shore area and from more than ten other area hospitals. 

LEADERSHIP AND CHAMPIONS

            PCCHNS has had the same chief executive since 1990 and the same medical director since 1989. The medical director, who at one time was chief resident in internal medicine at Evanston Hospital and is a nationally prominent leader in hospice and palliative medicine, has played a key leadership role in the hospital collaboration.

RNSMC’s current president and its chair of medicine both have been instrumental in advancing the partnership. In opening the hospice unit with such a short turnaround, PCCHNS also enjoyed the support of the hospital’s facility director and other senior staff, the chair of the hospital’s Board of Directors, the construction crew and leaders in the community, including the Mayor of Skokie.

EDUCATION AND RESEARCH

             Plans are being finalized for rotating Rush internal medicine residents through a clinical experience on the hospice unit at RNSMC, and discussions are underway with several area hospitals about establishing a palliative care residency. PCCHNS is also a participating site in the MediCaring Demonstration Project sponsored by RAND Center to Improve Care of the Dying, and launched a palliative care fellowship in July 2001 with significant financial support from RNSMC and Washington Square Health Foundation.

CHALLENGES OF IMPLEMENTATION

Ø       PCCHNS’ Medicare hospice reimbursement rates were cut in 2000 by a net amount of 2.5 percent – even counting an annual cost-of-living increase – through the annual adjustment of the regional wage component of Medicare’s rates.

Ø       PCCHNS was challenged to move its established, well-functioning hospice inpatient unit on very short notice, while the high cost of local real estate and high occupancy rates at area hospitals limited the available options.

Ø       The complexities of different reimbursement systems for patients with palliative care needs have fully challenged PCCHNS’ management capacity. The financial implications for the overall organization from various pilot programs within its continuum have been difficult to project.

Ø       The organization has consolidated a large number of organizational changes and new programs in recent years, accompanied by the need for internal staff education and cross training.

KEYS TO SUCCESS

Ø       A shared vision of palliative care by PCCHNS’ senior management and medical leadership.

Ø       PCCHNS’ independence, reputation and high profile in the community.

Ø       A high degree of mutual respect between RNSMC and PCCHNS.

Ø       A close working relationship with the Illinois Department of Health and the department’s commitment to the success of the inpatient unit at RNSMC.

Ø       The hospice unit’s location on the hospital’s campus but outside of the main hospital building, allowing it to draw upon hospital resources such as the surgery and emergency departments while simultaneously creating an identity as a community resource.

Ø       PCCHNS’ active role on advocacy on the local, state and national levels, including extensive dialogue with regulators and fiscal intermediaries.

LESSONS LEARNED

Ø       Hospital culture can be influenced by a strong daily presence for hospice and palliative care through interacting with nurses and other staff, daily rounding and informal consultations.

Ø       Hospice inpatient units can be almost as service-intensive as intensive care units when measured in terms of the frequency of medication adjustments and other changes in the plan of care.

Ø       If the hospice program is going to invest in renovating and establishing an inpatient unit within a leased hospital setting, it should obtain contractual assurances that the lease will not be arbitrarily withdrawn.

Ø       If acute care beds are at a premium, it may be advisable to consider beds that are licensed at a different level of care. For PCCHNS, having its inpatient beds licensed as psychiatric hospital beds has presented no significant downsides.

Ø       When first introduced, palliative care services may not be as well-understood or appropriately utilized as hospice care, which is a more familiar concept for health professionals.

Ø       Hospice care and palliative home care are distinct, differently regulated programs, optimally operating independent from, rather than subordinate to, one another. (For example, at PCCHNS, both divisions report independently to the agency’s vice president of clinical services.)

Ø       Reimbursement is available for a range of palliative care services in a variety of settings, but the provider of a palliative care continuum is challenged to efficiently tap those sources.

Ø       Some dying patients may never be able to accept the hospice concept, but if a functioning continuum of palliative care is in place, patients can still be directed to an appropriate level of care for their needs.

NEXT STEPS

PCCHNS is busy planning a number of potential next steps in solidifying and advancing its continuum of palliative care services – some in collaboration with RNSMC – including the following:

Ø       Participation with RNSMC in the MediCaring pilot study for patients with chronic-obstructive pulmonary disease and congestive heart failure.

Ø       Implementing a palliative medicine fellowship, exploring a palliative care residency program with area hospitals and participating in hospice rotations at RNSMC for internal medicine residents.

Ø       Establishing PCCHNS’ palliative care team as a core service in a planned new cancer center on the RNSMC campus.

Ø       Growth for the palliative care consultation service (building on a significant increase in physician visits during the first two months of 2001), with further outreach targeting cardiovascular, orthopedic and dementia patients.

Ø       Establishing a non-Medicare, home care-licensed division to provide private-pay professional services in the home without the constraints of Medicare’s home health regulations.

Ø       Exploring the ramifications of developing an incorporated physician practice model.

Ø       Further extending community outreach, care management and palliative care clinic consultations to assisted living facilities and continuing care retirement communities.

Ø       Expanding PCCHNS’ infrastructure (office space, information technology, website, corporate endowment, etc.) through a capital campaign.

Ø       Participation in exploration of a collaborative, multi-specialty geriatric outpatient clinic on RNSMC’s campus.

 
Sidebar: PCCHNS Service Statistics 2000
Hospice patients1,189
Inpatient unit admissions466
Average length of stay, hospice care49 days (median: 11 days)
Average length of stay, hospice unit9 days
Home health care patients424
Visits7,363
Bereavement clients1,473
Adults1,200
Families with children273
Pediatric clients21
Community pediatric consults15
Average daily census:
Hospice165 (nearly 200 in 2001)
Home health care70
Community outreach250 (active cases)
Bereavement700 (ongoing)
HomeCare Assistants60 (per month)
Palliative care consults50 (per month)
Care Center for Kids30 (per year)
Palliative care consultation visits in 2000480
Nurse160
Physician240
Social Worker73

Nearly 60-70 ongoing patient consultations in all settings (home, long-term care, assisted living facilities, hospitals, outpatient clinics, and inpatient hospice unit in 2001.

 

 


Additional Resources

The Advanced Illness Assistance Program at Blount Memorial Hospital, Maryville Tennessee
This program is an evolving integrated palliative care program including Medicare approved home hospice and consultative services in the outpatient, home health and inpatient settings.

Building from the Bottom Up: The Palliative Care Program at the Medical College of Wisconsin
Palliative care visionary and medical educator David E. Weissman, MD, reviews the decade of hard work and commitment behind establishment of the Palliative Care Medicine Program at the Medical College of Wisconsin in Milwaukee.



Other Resources By



back to top