| Philosophy/Approach | - Consultative service- Doctor (MD) or advanced nurse practitioner (ANP) provides initial assessment and communication with attending physician, nursing, and social work staff- May or may not write patient orders- MD or ANP refers patients to needed services (such as social work), discusses needs in conference, and communicates clinicians- Assists patient and family with advance directives and plans for future
| - Consultative service with full team of doctor, ANP or nurse, and social worker 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 settings, discusses needs in conference, and communicates with all team members
| - 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- Approach is milieu intensive as well as individual patient-focused- Care reimbursed under licensure and guidelines (eg, acute care)
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| 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 mission- MD or ANP develops protocols for patient care in conjunction with treatment team, educates staff about palliative care and protocols
| - 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 mission
| - Patients referred to palliative care program are screened by team for appropriateness- 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
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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)
| - 0.5 to one FTE medical director- One FTE ANP- 0.5 medical social worker- One FTE clerical support- Access to and time allotted for social work, nursing, PT, OT, and pharmacy to respond to referrals (should be monitored for time requirements)- 0.2 FTE finance person
| - 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.
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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 teaching as well.- Literature does not define volume but anecdotal reports suggest maximum comfortable caseload of 4 new cases per day and average census of 10 patients/week
| - 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
| - 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
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| Benefits/Advantages | - 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
| - 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
| - 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
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| Disadvantages/Threats | - 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 need to be educated
| - 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 educated
| - 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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