Center to Advance Palliative Care

My small catholic based hospital has been providing outreach palliative care services for over the last 6 years. It is a social worker based program - staffed by one social worker to make home visits to address the psycho-social issues of those struggling w/life-limiting illnesses. Over the past 6 years I have received over 800 referrals. I also see patients in the clinic setting when they are in to see their physician. We do not charge for palliative services as it is part of our catholic mission. Within the confines of this service, the primary care physician or oncologist and their nurse; the patient's clergy and myself make up the interdisciplinary team. It has been a wonderful program to fill the gaps between home health services and hospice. The people I work with- usually fall between these cracks. If they do qualify for home health, I take a step back until they are no longer involved although sometimes I work closely w/them. I also work very closely w/the county social workers. We try not to duplicate services and my specialty is helping the patient w/the medical issues and also ensure that the everyone is on the same page w/the same goals in mind. A majority of my patients are transitioned to hospice.

I also have an inpatient consultation program. I see an average of 20 patients inhouse every month and have an average of 15-20 patients in the outreach program. For the inpatient program, I work jointly with the discharge planners, and again, try not to duplicate services but ensure that everyone has a clear understanding of the goals of care.

Since I am a social worker I am not necessarily a threat to the physicians and they are my leading referral source. My inpatient "team" consists of the primary care physician, the patient's nurse for the day; staff spiritual services as well as the discharge planners; dieticians; therapists; etc.

I do have a medical director that I go to for information; advice; guidance; etc butI am the only palliative care staff person.