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.
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.
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
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:
licensed, JCAHO-accredited home health agency, which has been somewhat
constrained recently by implementation of Medicare’s home health prospective
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
comprehensive pediatric hospice and palliative care program in collaboration
with Children’s Memorial Hospital, which includes a contract for inpatient beds
at the hospital.
bereavement camp and other specialized pediatric services.
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.
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
hospice inpatient unit, operated in leased space on the campus of
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.
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.
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.
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
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
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
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.
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.
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.
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.
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
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.
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
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
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.
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
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
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.
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.
vision of palliative care by PCCHNS’ senior management and medical
independence, reputation and high profile in the
degree of mutual respect between RNSMC and PCCHNS.
working relationship with the Illinois Department of Health and the department’s
commitment to the success of the inpatient unit at RNSMC.
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
active role on advocacy on the local, state and national levels, including
extensive dialogue with regulators and fiscal intermediaries.
culture can be influenced by a strong daily presence for hospice and palliative
care through interacting with nurses and other staff, daily rounding and
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.
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.
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
first introduced, palliative care services may not be as well-understood or
appropriately utilized as hospice care, which is a more familiar concept for
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.)
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
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.
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:
with RNSMC in the MediCaring pilot study for patients with chronic-obstructive
pulmonary disease and congestive heart failure.
a palliative medicine fellowship, exploring a palliative care residency program
with area hospitals and participating in hospice rotations at RNSMC for internal
PCCHNS’ palliative care team as a core service in a planned new cancer center on
the RNSMC campus.
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
a non-Medicare, home care-licensed division to provide private-pay professional
services in the home without the constraints of Medicare’s home health
the ramifications of developing an incorporated physician practice
extending community outreach, care management and palliative care clinic
consultations to assisted living facilities and continuing care retirement
PCCHNS’ infrastructure (office space, information technology, website, corporate
endowment, etc.) through a capital campaign.
in exploration of a collaborative, multi-specialty geriatric outpatient clinic
on RNSMC’s campus.
PCCHNS Service Statistics 2000
|Inpatient unit admissions||466|
|Average length of stay, hospice care||49 days (median: 11 days)|
|Average length of stay, hospice unit||9 days|
|Home health care patients||424|
|Families with children||273|
|Community pediatric consults||15|
|Average daily census:|
|Hospice||165 (nearly 200 in 2001)|
|Home health care||70|
|Community outreach||250 (active cases)|
|HomeCare Assistants||60 (per month)|
|Palliative care consults||50 (per month)|
|Care Center for Kids||30 (per year)|
|Palliative care consultation visits in 2000||480|
60-70 ongoing patient consultations in all settings (home, long-term care,
assisted living facilities, hospitals, outpatient clinics, and inpatient hospice
unit in 2001.