How to Conduct a Hospital and Community Needs Assessment
Hospital and community data can be used to illustrate the scale of unmet need and to target vulnerable populations.
Developing a new clinical service requires supporting data that establish the need for and feasibility of the proposed program. The process of assessing institutional and community need for a palliative care program often leads to enhanced dialogue, broadened institutional recognition of the importance of palliative care and engagement of a critical mass of influential hospital opinion leaders.1 Hospital planning staff should be able to provide assistance in developing an organized needs assessment process and plan with the goal of generating convincing data demonstrating compelling patient care quality issues.
Collect and Analyze Data
In addition to articulating how the new palliative care program will support the institution's overall mission and vision, it is important to collect and analyze some hospital and community data before and after beginning the program.
Community analysis will require a review of patient/population demographics, economic trends and already existing palliative care and pain management resources. Hospital and patient analysis may involve a review of medical records (for more detailed descriptions of the care delivered to dying patients in your hospital) or hospital databases (with information on patient volume, demographics and financial data).2,3 Data requirements will vary depending upon type of institution and the extent to which institutional leadership is, or is not, pre-disposed to supporting development of a palliative care service.
These data can be used to graphically illustrate the scale of the unmet need and to identify patient populations that can benefit most from a palliative care service. (e.g., patients with cancer, chronic degenerative diseases of old age, patients dying in the ICU and on ventilators). To the extent possible, it will be helpful to demonstrate costs to the hospital (in length of stay and ancillary expenses) for failing to identify and institute appropriate services and discharge options for this vulnerable, complex and seriously ill patient population, many of whom are dying.4
Data assessing sources of suffering in seriously ill and dying patients in the hospital also create a compelling argument for palliative care services. A brief pilot survey on pain intensity and associated opiate or other analgesic prescribing (or lack thereof) in a small cohort of hospitalized cancer or ICU patients at two or three defined time periods can yield powerful data supporting the need for change.
Focus groups are another cost-effective way to identify and publicize the need for palliative care services in a targeted population. Focus groups can reinforce program rationale as well as reveal problems and needs that may have been overlooked.5 Several four- to six-person homogeneous focus groups can be organized as follows:
- Physicians caring for the target population;
- Nurses, social workers, pharmacists and chaplains;
- Patients in the target diagnostic group or groups;
- Family caregivers; and
- Community representatives.
Assess Inpatient Acuity and Resource Use
Hospitalized palliative care patients typically have complex, serious illnesses. Their lengths of stay are long and costs of care are high. DRG assignments do not fully reflect these realities. Consequently, case mix indexing is usually necessary to ensure that cost and resource use comparisons are equitable for palliative care programs versus other hospital services.
Case severity and complexity are often assessed using chart review with APACHE coding (patient service severity measurement software) or the Charlson Comorbidity Index.6,7
The most commonly employed measure of hospital resource use is the Therapeutic Intervention Scoring System, Version 7 (TISS).8
A recent study demonstrated a direct correlation between TISS and hospital costs in the ICU.9 Attaching a dollar value per point to the TISS scale for example $350 per TISS point per day allows the institution to project the potential dollars saved through reductions in resource use and length of stay related to introduction of a palliative care service. The Detroit Receiving Hospital's palliative care program estimated a nearly 50% reduction in use of hospital interventions (by TISS) when patient care goals were changed from acute supportive or life-prolonging efforts to palliative and comfort care measures only.10,11,12,13
In addition, there are hypothetical cost savings associated with reductions in length of stay through more timely identification of patients with a terminal prognosis, facilitation of patient or surrogate decisions to receive on-going care outside the hospital (e.g., home with hospice care, home care or nursing home care), or decisions to forego further attempts at disease-modifying or life-sustaining therapy.14,15 It also may be possible to document reductions in medically unnecessary, costly and burdensome medical interventions and procedures as patients near the end of life.16,17,18,19,20-24
Community Need and Opportunities for Collaboration
Lastly, the needs assessment should identify and evaluate all community resources that provide palliative care, hospice, pain management, home health and nursing home care as well as other services that deliver care for patients with chronic disease or patients who are nearing the end of their lives. (A portion of this information will come from interviews of hospital leaders and key stakeholders.) Useful information includes:
- Services available and length of time in existence;
- Reputation among patients and providers;
- Ability to satisfy community need for palliative care; and
- Gaps in currently provided services and how your proposed palliative care program might help fill these gaps.
The goal is to identify how the proposed palliative care program might facilitate "win-win" collaborative opportunities with other providers in the community. This process will also help determine whether it is better for the institution to "build" its own palliative care program or "buy" services through a contractual arrangement(s) with existing community providers such as hospice.
Assessing the Interest of Institutional Leaders
Opinion leaders and stakeholders can open doors.
An important step in the palliative care program planning process involves assessing the interest of institutional leaders. This step will help reconcile your priorities with those of the hospital, with the existence of similar or competing services and with the needs of patients and families. Hospital leadership will require a sound justification that incorporates a realistic business plan before approving new resources for a service that may have substantial difficulty covering its operating costs, let alone generating additional revenue.
One way to begin this analysis is by interviewing the various stakeholders likely to be affected by the new program. Taking the time to listen to other perspectives on care of the dying in your hospital (and in general) may go a long way toward enlisting support for your proposal. A summary of findings from these discussions that documents the support and interest of institutional leaders should be part of your overall business plan.
Each community and institution has unique opinion leaders and stakeholders such as:
- The governing board and administrative leaders from
the hospital, nursing, social work and chaplaincy;
- Patients and families (the customer);
- Hospital-based and community physicians including
general and family medicine, pediatrics, critical care, oncology, pulmonary,
cardiology and infectious diseases;
- Community and religious leaders;
- Key community employers; and
- Other community healthcare providers.
Based on discussions with opinion leaders and stakeholders, you will be able to identify palliative care champions. Commitment from these individuals will be necessary to influence the institutional culture to accept the new model of care represented by palliative medicine. Ideally, some of these individuals will represent the mainstream of the hospital's culture, command the respect and attention of their colleagues and be influential in establishing a consensus among their peers.
During scheduled one-on-one meetings with these stakeholders and key constituents, explain and discuss the concept of palliative care and its differences from (and similarities to) hospice. Present your assessment of hospital and community need. Point out the significant advantages of creating a palliative care program, especially in terms of the delivery of excellent compassionate care to the hospital's most vulnerable and needy patients and families. Ask if the individual has had any personal or professional experiences with these types of issues and if he or she believes that such a program would be consistent with the hospital's mission to provide high-quality patient care.
In meetings with hospital administrators, it may be appropriate to discuss how a palliative care program might influence costs related to length of stay and to ancillary services associated with hospital care of the seriously ill and dying. Ask for advice on next steps, on how to secure funding and on identifying others who might be important or helpful. Before you leave the meeting, ask if the individual will support the palliative care initiative, in both general and specific terms.
1. Hamel MB, Davis RB, Teno JM, Knaus
WA, Lynn J, Harrell F, Galanos AN, Wu AW, Phillips RS for
the SUPPORT Investigators. Older Age, Aggressiveness of Care, and Survival
for Seriously Ill, Hospitalized Adults. Ann Intern Med 1999;131:721-728.
PubMed, a service of the National Library of
Medicine, provides access to over 11 million citations from MEDLINE and
additional life science journals. PubMed includes links to many sites providing
full text articles and other related resources. Visit: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed
Session C: Financing a Palliative Care Program
Session D: Developing a Financial Plan
CAPC Marketing Tool: How to Promote Palliative Care at Your Hospital
Web Usability Survey
We want your input! This document is designed to get feedback regarding how easy our site (www.capc.org) is to use.
Physician's Survey: a Needs Assessment Tool to Build Support
This downloadable survey is designed for leadership to distribute within their institution. It can be used as a marketing tool to help assess attitudes, educate colleagues, solicit input and build a strong case for creating a palliative care program.
Palliative Care in Hospitals: Making the Case
A CAPC Management Training Seminar
February, 2002 Tampa, FL
Defining Objectives (session 1 worksheet 1)
From a list of Possible Palliative Care Program Objectives, the user of this worksheet will be able to rank their objectives and that of their institution.
Identifying Stakeholders (session 1 worksheet 2)
Creating an array that broadly identifies people who may be stakeholders is an important step in developing a program design, an approval strategy, and an implementation strategy. The above sheets focus on a “first cut” to help identify players.
Drafting your “dream teams” (session 1 worksheet 3)
Planning for Structure: Committees and Workgroups. This 3 page form builds upon the Identifying Stakeholders worksheet by asking the user to identify appropriate people for a Steering Committee, a Design Workgroup and a Proposed Team.
Positioning Palliative Care to meet Organizational Needs (session 2 worksheet 2)
a 1 page form which builds upon the topical areas of worksheet 1 by looking at a palliative care program's potential contributions.
Summary Program Assessment (Session 3)
Summary questionaire to assess the goals, scale, needs, type, obstacles, measurements of success, Roles and Responsibilities of a palliative care program.
Making the Case for a Palliative Care Program
Gathering Supportive Data
A CAPC Fall Forum 2000 Workshop
Supportive Care of the Dying
Personnel Performance Evaluation:
Standards for all professionals who provide End Of Life Care
Toolkit of Instruments to Measure Care at the End of Life
An authoritative bibliography of instruments to measure the quality of care and quality of life for dying patients and their families.