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Palliative care program is passion for smaller hospice
Hospice makes it work for community's sake
When leaders at Coastal Hospice in Salisbury, MD, decided to move toward a palliative care philosophy, one of their first actions was to visit a Center to Advance Palliative Care (CAPC) site at the Palliative Care Center of the Bluegrass in Lexington, KY.
"We chose that hospice because it has a palliative care program and collaborates well with several medical centers in its area, and we thought their model would fit with us because we're not hospital-based," says Marion F. Keenan, MA, MBA, president of Coastal Hospice.
"So we went to that center of excellence in July, 2005, and we were there for a week studying the palliative care program," Keenan recalls. "We started to write our own plan when we were there and wrote a proposal to give to our board."
Hospice leaders presented the palliative care plan to the hospice board a few months later. The plan included collaboration and a contract with Peninsula Regional Medical Center in Salisbury, Keenan says.
"Concurrently, the nurse executive at Peninsula Regional Medical Center, our initial partner institution, also took the plan to its various levels for approval and got that approval," Keenan says. "It was a limited approval on both sides."
The hospice board said the hospice could move forward and begin to implement the plan, which was funded in part by a stipend from the hospital in exchange for palliative care services upon request, she notes.
"We began to do informal palliative care consults, starting around November, 2005, at Peninsula Regional," Keenan says.
Since the hospice's medical director had a long-standing relationship with the hospital and its medical staff, the physician buy-in went smoothly, she said.
"That was a huge asset," Keenan says.
The hospice's medical director gave presentations about palliative care at the medical society meetings and to various medical-surgical departments at the medical center, Keenan says.
The palliative care program requires a primary physician, or another person in charge at the hospital, to make a request for a palliative care consultation, and then the hospice conducts the palliative consultation through a team that includes a physician, a nurse practitioner, a social worker, and a pastoral counselor, she explains.
Plus, the hospice formed a professional medical advisory committee that consists of local physicians, a nurse educator, and people in the community, including an attorney, she says.
The second tier of leadership is a small leadership group that consists of Keenan, a hospice financial director, the hospice medical director, a clinical vice president, and three leaders from Peninsula Regional. This committee originally met monthly, although such frequent meetings have not been as necessary as the palliative care program matures, she says.
And the final tier is a palliative care workgroup that meets more frequently and consists of all the people in the leadership group plus front-line staff, including a hospice and hospital social worker, a hospital and hospice pastoral worker, Keenan says.
All three groups help resolve any issues that arise as a result of the palliative care collaboration.
For instance, if a hospice pastoral counselor needs to enter an electronic medical record at the hospital, but doesn't have the password, authorization, and training that's necessary, then she might bring this problem to the workgroup, Keenan says.
"Probably what would happen is within the workgroup we'd learn that the authorization isn't functioning, and so we'd take it up to the executive level and try to unclog this little problem," Keenan explains. "Then the chief nurse executive at the hospital would say, 'I know how to do this, and we would troubleshoot and make it easier for the front-line team to handle."
The palliative care team often receives referrals to work with a patient in the intensive care unit (ICU) before the patient is discharged, Keenan says.
"We'll talk with the home health agency and maybe consult with them, and we'll provide a nursing consultation to patients who have chronic illnesses where they'll eventually become hospice patients," she says. "Long-term care facilities are also in our palliative care plan, but we have not started with that yet."
The stipend from the hospital helps defray the palliative care team's costs, but there have been costs above and beyond it, she notes.
However, there are benefits to offset any financial drawbacks, however.
"The whole idea of palliative care is that we see people who were two years away from being hospice eligible," Keenan says.
This goal directs the hospice toward community care, and it has the potential to direct more patients to hospice care and direct them sooner than perhaps they would have before the palliative care program was implemented, she says.
"We have a sense of moral responsibility to our community more than anything else," Keenan says. "We have the tools to help people and families who are confronting a terminal illness, and our work is very similar to helping people confront a serious chronic illness."
Patients and families in a hospital's intensive care unit (ICU) face many of the same end-of-life issues faced by hospice patients, only they may be facing these issues all at once in a crisis mode.
"Unlike patients with diseases that have existed for a long time, these families are right there, deciding what's right for the patient as a family unit," Keenan says. "We just think it's part of our mission to help them do that, and we'll do it as long as we're not financially undermining our hospice."