the types of collaborative palliative care programs and services being developed by hospital and hospice partners include the following contract related to the medicare hospice benefit most often defining protocols for the hospital to refer patients in need of hospice care to the hospice program and/or for the hospice program to refer its patients in need of inpatient care to the hospital hospice liaison nurse position based at the hospital hospice team based at the hospital to facilitate hospice admissions and care management for the hospice s patients who are in the hospital hospice inpatient unit acute palliative care unit which may include hospice beds smaller-scale comfort suite with one or more environmentally enhanced beds preferentially available for dying patients inpatient palliative care consultation service that goes anywhere in the hospital to share palliative care expertise outpatient clinic-based home-based and/or nursing-home palliative care consultation separately i
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acute care and on disease treatment as opposed to the strictly palliative and comfort-focused orientation of hospice programs such differences in institutional mission are likely to be reinforced in the attitudes of staff and in the overall organizational culture recent evidence suggests however that those differences in focus are changing in light of greater recognition by hospital leaders of the importance of improving symptom management communication and supportive services for seriously and terminally ill inpatients and their families new pain management standards issued by jcaho in january 2001 have also helped to raise awareness of the need for palliative care in the hospital setting in addition there is growing recognition among hospital and hospice leaders that patients and families are in need of indeed demanding a more effective continuum of care from their local delivery system and that community healthcare providers have a responsibility to assure that such a continuum is a
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inpatient care include patients in need of medication adjustment observation or other stabilizing treatment or a patient whose family is unwilling to permit needed care to be furnished in the home.30 for care and services provided starting october 1 2001 the general inpatient care rate is $491.19 the medicare benefit includes a provision referred to as the inpatient care limitation which specifies that the total number of inpatient days used by medicare patients of a certified hospice program in the aggregate may not exceed 20 percent of the total number of hospice days billed by that hospice in a given year in addition to the inpatient care limitation hospice programs are subject to an overall limit on medicare reimbursement known as the hospice cap the cap amount is adjusted annually and each hospice program s total allowed payment is calculated by multiplying the cap amount by the number of medicare beneficiaries who have elected to receive hospice care from the hospice during that
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5 three hospitals and a hospice lexington ky model/summary community-based hospice of the currently the agency has an average daily census of nearly 600 hospice patients two-thirds of them served by its lexington central program and the rest from separately certified offices in eastern and northern kentucky the state s certificate of need law for hospice care which has tended to dampen competitive pressures and hob s high average length of stay of 81 days median 33 days have also contributed to its financial stability and ability to innovate hob offers other specialized services including a federally funded children s hospice demonstration project a manage average of 378 patients per year one-third of whom were never referred for hospice care after the initial grant ended ukcmc agreed to hire the liaison nurse on staff and cover approximately 80 percent of the position s salary related to discharge planning and palliative care functions the 15 hospice programs together pay the remai
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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 pcc 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 pcc s 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 re-evaluating 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 force visited other hospice and p
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tion issues palliative care is provided by staff from hpcg on a subcontracting basis under the home health agency s license and certification b a fee-for-service consultation and case management service called transitions life choices tlc offered to the public and designed to support people who are confronting life-limiting illnesses in making important life-transition decisions c a hospital rapid response team d a palliative care consultation service the project s director is a physician who is also trained as a social worker formerly on the internal medicine teaching faculty at moses cone hospital she concurrently serves as hpcg s associate medical director and as medical director for its beacon place residence originally hpcg s role in the initiative was conceived more as change agent and catalyst for the hospitals to expand their involvement in palliative care however competing issues for the hospitals such as the need to consolidate their merger created a vacuum for hpcg to assu
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follow-up and an inclusive approach to the needs of patients and families ultimately the measure of the new department s impact on the medical culture at bimc will be seen in increased referrals overall for palliative care although department staff believes it may take years to achieve a major medical center can provide a setting for a hospice program to interface more directly with conventional medical care encourage end-of-life dialogue and more appropriate referrals and begin to influence the overall medical culture of the institution 9 a research and planning group for palliative care sacramento ca model/summary a research and planning group within the health system and teaching hospital affiliated with the university of california-davis medical school has been experimenting with grant-funded projects targeting narrowly defined populations in order to advance palliative care concepts within the system the health system s long-established hospice program has provided both a settin
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exploring opportunities for working more closely with hbb although ucsf has not seriously considered an inpatient 11 a regional palliative care initiative lebanon nh summary/model in recent years dartmouth-hitchcock medical center a teaching hospital in lebanon nh has pursued grant-funded end-of-life care projects that are regional in scope collaborating with hospice vnh a bi-state home-health-agency-based hospice program headquartered in nearby white river junction vt in january 2001 dartmouth launched an academic inpatient and outpatient palliative care consultation service building on its previous initiatives and having the potential to become an end-of-life care resource for the region hospice vnh a program of visiting nurse alliance of vermont and new hampshire a regional home health agency with nine offices provides medicare-certified hospice care across significant portions of southeastern vermont and southern new hampshire the hospice program has two geographic teams each with
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physicians grow they would be used to handle the most routine palliative care cases calling in the consulting team for more complicated cases keeping the service open with the attending physician remaining in charge of cases and the consulting physician in an barre designated beds didn t make sense for the relatively small rural hospital nurses often develop relationships with patients dying in the hospital which would be disrupted by moving a patient off the floor to a dying room the definition of palliative care has broadened to include anyone with a serious illness and symptomatic needs demand has grown from just six referrals in the first four months to an average of four to six referrals per month by the challenges of implementation burlington arm s-length advisory capacity early visible successes especially with icu cases and difficult family dynamics the team s emphasis on teaching by demonstration a flexible approach toward adapting palliative care concepts to its unique
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14 concluding observations the following conclusions summarize key issues challenges requirements limitations and funding mechanisms of the medicare hospice benefit outlined in chapter 2 hospice providers increasingly are unwilling to be constrained or exclusively defined by medicare s model of hospice care in trying to broaden the practice of hospice care beyond medicare limitations such as its requirement for a sixcollaboration is possible and effective most importantly the case studies in this report illustrate how hospitals and hospices in different communities each with particular advantages and difficulties have come together to implement creative strategies for improving the care given to hospitalized patients with serious and life-threatening illnesses and their families the varied collaborative approaches and responses undertaken at the sites reflect their unique settings and circumstances and address identified unmet local needs these experiences clearly demonstrate that col
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hospice vnh 46 s main st white river junction vt 05001 marie kirn hospice coordinator 802/295-2604 marie.kirn@hitchcock.org 8 barre vt central vermont home health hospice rr 3 box 6694 barre vt 05641 diana peirce hospice coordinator 802/223-1878 diana.peirce@hitchcock.org 8 burlington vt fletcher allen health care zail berry m.d palliative care service c/o 1 timber ln s burlington vt 05403 802/847-5156 zail.berry@vtmednet.org 9 hollywood/miami fl vitas healthcare corp 100 s biscayne blvd miami fl 33131 linda neiber director of inpatient development 305/350-6010 linda.neiber@vitas.com j.r williams m.d chief medical officer 305/350-5923 jr.williams@vitas.com memorial regional hospital j.e piriz administrator jpiriz@mhs.net.com 71
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