Characteristics

Solo Practitioner Model

Full Team Model

Geographic 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.