Description

Evergreen Palliative Care is a community based Palliative Care (PC) program under the umbrella of Evergreen Home Care Services (EHCS), which also includes Home Health, Behavioral Health and Hospice. Since 2006, the PC Licensed Clinical Social Worker (LICSW) has provided consultative decision making services in patients’ residences. In late 2010, Evergreen PC was awarded a Sojourns Innovative Grant from the Regence Foundation. Our goals included adding ARNP services and focusing on building partnerships with local Skilled Nursing Facilities (SNF) to better serve SNF residents. We have created a partnership with a local SNF to provide ARNP and/or LICSW services to patients and/or families. Many of the SNF patients are recently discharged from our hospital, Evergreen Hospital Medical Center. The ARNP coordinates with our Hospital Liaison staff (funded by EHCS), and visits the SNF patient typically while they receive rehab services. The ARNP services are billable consultative symptom management and decision making services, in collaboration with the patient, family, SNF Medical Director and staff. The LICSW participates as indicated. The Palliative Care ARNP and LICSW continue to follow the patient in the community (if appropriate) in order to strengthen the continuity between hospital, SNF and home settings.