Leadership
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Writing A Business Plan
Reimbursement
Delivery Models
Inter-Disciplinary Team
Program Operations
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Organizational Models for Palliative Care

One delivery model will not fit the needs of every institution.

Palliative care program planning includes selecting an appropriate service delivery model. This critical decision is based on several factors:

  • What target populations does the program intend to serve? A complex, tertiary care referral population with a high proportion of critically ill, technology-dependent patients? Or a small community-hospital population of mostly elderly and chronically ill patients?
  • Where do most patients die within your hospital and service area (ICU, medical/surgical ward, home, nursing home, in-patient community hospice facility)?
  • Will inpatient bed constraints dictate the type of service model that best fits your hospital?

While many different palliative care program models exist, no evaluative data are available to assess their relative strengths and weaknesses. It is evident, however, that one model does not fit the needs and resources of every institution. Selecting the "right" model may be a function of patient load, physician practice patterns and culture, availability of trained palliative care staff, and other circumstances. Common organizational models for palliative care programs include the following:

Consultation service

A consultation service team is typically composed of doctors, nurses and social workers, who see patients with palliative care needs anywhere in the hospital. The consultation format is a good mechanism for introducing the palliative care service throughout the hospital because it reaches the largest possible number of nurses and physicians through bedside and nursing station teaching and role modeling. Its primary disadvantage is that a consultant is only an advisor to the patient's primary physician and his or her recommendations may or may not be followed. In addition, depending upon training and experience, some hospital staff may or may not be comfortable with a role in palliative care (e.g., administering opiates for dyspnea or titrating analgesics for pain relief).

Dedicated inpatient unit
In this model, palliative care beds are clustered on one unit, allowing concentration of patients with like needs in one place. Nursing staff quickly become skilled and comfortable with both pharmacologic and psychosocial approaches to patient and family, and the palliative care approach is less likely to be resisted or feared by the primary physician. The disadvantage of this model is that the geographic patient concentration deprives staff in other parts of the hospital from exposure to the service and learning opportunities about palliative care skills that every doctor and nurse needs.

Inpatient hospice and palliative care units typically contain at least 15 beds, largely based on staffing ratio considerations. Some programs situate their unit where the complex, seriously ill patient population already resides and where the staff is likely to be trained in competent and compassionate care of the seriously ill. Where possible, select a unit with patient rooms that have space for a family member to stay overnight as well as a conference room or lounge large enough to hold regular family and staff meetings.

Combined consultative and geographic unit model

A number of the pioneering programs for hospital-based palliative care have established combined programs with a consultation service and a dedicated inpatient unit. 1, 2, 3-5, 6, 7-11 These programs have attempted to achieve the benefits of both models. The major limitations of such an approach may be the availability of professional staff and beds.

Combined hospice palliative care unit (with or without a contract with a community hospice)

Several hospitals have established geographic inpatient units that serve both hospice patients as well as hospital patients who have palliative care needs. The payment sources on such units may include Medicare hospice inpatient per diem, Medicare Part A, inpatient DRG and other insurers (e.g., Medicaid and commercial). Because the needs of the patient populations are similar, regardless of payer, this model allows concentration of staff expertise and, theoretically, could enhance continuity of care from inpatient to home care to home hospice. Some programs have combined an inpatient unit with a contract for inpatient hospice care with a community hospice program (see sidebar "How Partnership Works"). 12, 13-15 The financial and contractual implications of such a hospice-hospital relationship will vary between programs.

Hospital outpatient palliative care clinic

If resources permit, establishment of an outpatient palliative care clinic, in combination with one or more of the above services, will provide greater continuity of care after patients are discharged from the hospital.


Related References

1. Lindenauer PK, Pantilat SV, Katz PP, Wachter RM. Hospitalists and the Practice of Inpatient Medicine. Results of a Survey of the National Association of Inpatient Physicians. Ann Intern Med 1999;130:343-349.
http://www.annals.org

2. Hammes BJ, Rooney BL. Death and end-of-life planning in one Midwestern community. Arch Intern Med 1998;158:383-90.

3. Lynn J. Serving Patients Who May Die Soon and Their Families: The Role of Hospice and Other Services. JAMA 2001;285:925.
http://jama.ama-assn.org

4. Smeenk FWJM, van Haastregt JCM, de Witte LP, Crebolder HFJM. Effectiveness of home care programmes for patients with incurable cancer on their quality of life and time spent in hospital: systematic review. The British Medical BMJ 1998;316:1939-1944.
http://www.bmj.org/cgi/content/full/316/7149/1939

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


Additional Resources

Managing Financial Resources: A Work in Progress-Case Study
How to Fund Your Palliative Care Program
Module 1
June 2002, Seattle, WA
Gretchen Brown, MSW, Susan Swinford, BSW, MSW & Kay Ross, RN, MSN, AOCN
PowerPoint Presentation

Reimbursement for Hospice Services 1/2
How to Fund Your Palliative Care Program
Concurrent Session D Part 1
June 2002, Seattle, WA
Gretchen M. Brown, Connie A. Raffa, JD, LLM & Susan Swinford, BSW, MSW
PowerPoint Presentation

Palliative Care: Trends and Treatment Pathways
Detailed PowerPoint presentation ranging from Palliative Care definitions & models to sample patient care flow sheets.

Managed Care System -Grand Rounds Call
Richard Della Penna, MD discusses Kaiser Permanent Aging Network.

Sample Hospital/Hospice Contract
This document is one example of an inpatient service agreement. It has been provided courtesy of Connie A. Raffa, JD, LLM of the law firm Arent Fox.

Development and Implementation of an Inpatient Acute Palliative Care Service
Mount Carmel Health is a large nonprofit health care system in Central Ohio. It has three hospitals, two educational institutions and a hospice program.

Article provided courtesy Journal of Palliative Medicine.

Palliative Care: An Opportunity for Medicare
CAPC--funded report, Palliative Care: An Opportunity for Medicare, has been published and recently disseminated by CAPC. The publication focuses on regulatory and administrative changes that could be made by the Centers for Medicare and Medicaid services.

Capitated Systems -Grand Rounds
Kenneth Rosenfeld, MD, director of the Veteran's Integrated Palliative Program at the Greater Los Angeles VA Health Care System discusses palliative care in a capitated health care system. This is a Grand Rounds Conference Call.

Choosing a Model
A CAPC Management Training Seminar
February, 2002 Tampa, FL
PowerPoint Presentation

Structuring Hospital-Hospice Partnerships: Legal Issues
A CAPC Management Training Seminar
February, 2002 Tampa, FL
PowerPoint Presentation

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.

Live Fall Forum 2001 Webcast Available on CAPC Website
Developing a Compelling Business Case, Medicare Primer: Payments to Hospitals and Physicians and Alternative Models of Palliative Care Delivery sessions are available to view.

Hospital-Hospice Partnerships
A CAPC Fall Forum 2001 Workshop
October 2001, Chicago, IL
PowerPoint Presentation

Palliative Care in Nursing Home Settings
A CAPC Fall Forum 2001 Workshop
October 2001, Chicago, IL
PowerPoint Presentation

Hospital-Hospice Collaborations
A CAPC Fall Forum 2001 Workshop
October 2001, Chicago, IL
PowerPoint Presentation

Hospital-Hospice Collaborations -Grand Rounds
Martha Twaddle, MD, medical director, Hospice of the North Shore, hosts CAPC's grand rounds conference call on hospital-hospice collaborations. This audio file is available for download.

Alternative Models of Palliative Care Delivery: The Franklin Health Model
A CAPC Fall Forum 2001 Workshop
October 2001, Chicago, IL
PowerPoint Presentation

Mount Carmel Health System: A Community Hospital Continuum of Care Model
A CAPC Fall Forum 2001 Workshop
October 2001, Chicago, IL
PowerPoint Presentation

Palliative Care for Advanced Chronic Disease in the VA Healthcare System
A CAPC Fall Forum 2001 Workshop
October 2001, Chicago, IL
PowerPoint Presentation

Selecting an Organizational Model for a Hospital-Based Palliative Care Program
A CAPC Fall Forum 2001 Workshop
October 2001, Chicago, IL
PowerPoint Presentation

Palliative Care in the Critical Care Unit
A CAPC Fall Forum 2001 Workshop
October 2001, Chicago, IL
PowerPoint Presentation

Keys to Successful Hospital-Hospice Collaboration: A Case Study
A CAPC Management Training Seminar
July 2001, Oakland, CA
PowerPoint Presentation

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.

Inpatient VA Hospice Care: Clinically Needed, Promoted by VERA
American Academy of Hospice and Palliative Care Medicine
Atlanta, GA

Serving Patients Who May Die Soon and Their Families: The Role of Hospice and Other Services
JAMA 2001

Palliative Care: Mainstream model -- Amednews.com -- The Newspaper for America's Physicians
Efforts to change the culture of dying in acute care settings are no longer on the fringes of medicine. Some physicians have proven that hospice-like care can coexist--and even cohabit--with hospitals.

Hospital-Hospice Relations: Emerging Partnerships and Collaborations
A CAPC Fall Forum 2000 Workshop
Audio Presentation

Restoring the Balance: Introduction to Palliative Care and Hospice
A PowerPoint Presentation

Square Pegs and Round Holes: Models of Care
Balm of Gilead Project Presentation

The Balm of Gilead Project
A CAPC Fall Forum 2000 Workshop
PowerPoint Presentation

Pioneer Programs in Palliative Care: Nine Case Studies
Milbank Memorial Fund

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.


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