Special note: This information on models of palliative care was adapted from material provided by the Center to Advance Palliative Care.
Adopted by George Hankins Hull Spiritual Care Coordinator LRGHealthcare
Solo Practitioner Model
Appropriate patients are transferred to service when they meet admission criteria
Palliative care team assumes responsibility for patient management and discharge planning. Patient may be followed on an outpatient basis after discharge.
Adopted by George Hankins Hull Spiritual Care Coordinator LRGHealthcare
Solo Practitioner Model
- Consultative service with Doctor (MD) or advanced nurse practitioner (ANP) provides initial assessment and communication with attending physician, nursing, and patient support staff.
- May or may not write patient orders.
- MD or ANP refers patients to needed services (e.g. social work, chaplain, dietitian, pharmacist, care manager, rehab therapist, pain management, alternative therapist or volunteer), discusses needs in patient conference, and communicates with clinicians.
- Assists patient and family with advance directives and plans for future.
Service Model
- MD or ANP receives referrals from attending physician, hospital staff, patient, or family.
- All units in hospital deliver palliative care as part of their stated mission.
- MD or ANP develops protocols for patient care in conjunction with treatment team, educates staff about palliative care and protocols.
Staffing and Budget Implications
- One FTE MD or ANP
- 0.2 FTE clerical support
- Access to and time allotted for social worker, nursing, physical and occupational therapists (PT and OT), and pharmacy to respond to referrals (should be monitored for time requirements)
- 0.2 FTE finance person
- 0.2 FTE medical director (if ANP-led)
Patient Volume Thresholds
- Patient coordination is intensive and ANP spends time with patient providing psychosocial support as well as symptom management and family teaching. Staff and community education.
- Literature does not define volume but anecdotal reports suggest maximum comfortable caseload of 4 new cases per day and average census of 10 patients weekly.
Benefits
- Lower start-up costs and financial risk.
- Opportunity to develop a program based on existing patient population
Less threatening to medical staff. - Builds on existing programs and services and uses them whenever possible.
- Program rests on one individual's shoulders.
- Patient volume quickly limited by workload.
- Service effectiveness is dependent on staff knowledge and cooperation.
- All units referring patients.
Full Team Model
Consultative service with full team of doctor, ANP or nurse and patient support staff assesses and follows patients referred by attending physician.
- Provides advice to primary physician, or may assume all or part of care of patient and/or write patient orders.
- Doctor bills fee-for-service as a consultant physician.
- Team refers patient to needed services and discharges to appropriate community settings, discusses needs in patient conference, and communicates with all team members.
Service Model
- Team works in unison to coordinate care plan and provide services.
- Social worker on team may assume role of case manager.
- Team develops and uses standing orders to manage patient.
- All hospital units deliver palliative care as part of their stated mission.
Staffing and Budget Implications
- 0.5 to one FTE medical director.
- One FTE ANP.
- 0.5 medical social worker/care manager
One FTE clerical support. - Access to and time allotted for social work, nursing, PT, OT, chaplain, dietitian, pain management, pharmacy and alternative therapists to respond to referrals (should be monitored for time requirements).
- 0.2 FTE finance person.
Patient Volume Thresholds
- Number varies, depending on whether patient is transferred to the team for all management.
- Can reach the largest number of patients and does not restrict the number of beds occupied by patients requiring palliative care services.
Benefits
- More medical expertise available.
- Provides alternative to medical staff that struggle with implementing new skills and knowledge.
- Consultative service reaches largest number of nurses and physicians through bedside and nursing station teaching and role modeling.
- Builds on existing programs and services and uses them whenever possible.
Disadvantages
- Added costs for team with limited, or no, additional revenue.
- Physician must establish rapport with many medical staff members; consultant serves as an advisor to the primary physician and recommendations may or may not be followed.
- Service effectiveness is dependent on staff knowledge and cooperation.
- All units referring patients need to be.
Geographic Model
- Inpatient program with all patients on designated unit.
- Inpatient staff team (doctor, ANP, social worker, chaplain, therapists) specially trained to provide palliative care manages patients.
- Staff is trained in palliative care and focuses on creating an inpatient environment supportive of patients and families.
Service Model
Palliative care team assumes responsibility for patient management and discharge planning.
Staffing and Budget Implications
- 0.5 to one FTE medical director.
- One FTE ANP.
- 0.5 – 1.0 FTE medical social worker.
- 0.5 – 1.0 FTE chaplain.
- 0.2 FTE finance person.
- Nurse manager.
- Inpatient unit staffing.
- Preferably, unit is situated where staff are likely to have training in fundamentals of palliative care.
- An allocation of DRG revenues may be required when a patient transfers from another unit to palliative care.
Patient Volume Thresholds
- Geographic unit approach allows the institution to designate beds, yet allow the number of beds to flex with patient volume.
- Most efficient staffing with 12 or more beds, preferably in rooms with space for family members to stay and room for staff and family members to meet.
- Because reimbursement is still acute care-oriented, the unit can flex to a capacity deemed appropriate to staffing levels and clinical expertise.
Benefits
- The program has a clinical milieu and staff to support it.
- Greater control over patient care.
- Higher visibility and influence within the hospital.
- Inpatient unit can be made patient-and family-friendly.
- May be easier to manage overuse of resources, length of stay.
- Opportunity for philanthropic support more easily developed.
- Can convert all or part of an existing unit to minimize additional staffing.
Disadvantage
- Geographic patient concentration deprives staff in other parts of the hospital from exposure to the service and learning opportunities.
- May be viewed as the "death ward," making physicians reluctant to refer patients.
- Unless beds can be shared efficiently with an adjacent unit, under-use of continuous nursing coverage beds due to low referral volume will translate into losses for the unit
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