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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptNIH Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
From:
Semin Oncol Nurs. Author manuscript; available in PMC Nov 1, 2011.
Published in final edited form as:
Semin Oncol Nurs. Nov 2010; 26(4): 266–284.
doi: 10.1016/j.soncn.2010.08.006
Table 3
Palliative Care Program Model Options
CharacteristicsSolo Practitioner
Model
Full Team ModelGeographic
Model
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)
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
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.
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
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
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.