As America's palliative care programs wrestle with balancing the growth opportunities and logistical demands that arise from opening and operating their own units, the palliative care program at Froedtert Hospital in Milwaukee, Wisconsin, has come up with a different wrinkle called the virtual inpatient unit. The virtual unit offers many of the benefits of a dedicated palliative care unit, including specialized care for palliative care patients, but without incurring the financial, operational and other risks of running a dedicated unit. At the same time it has identified unexpected morale benefits that may be relevant to other hospitals struggling with nursing staff shortages.

"We wanted dedicated space to establish our own unit to complement our palliative care consultation service," explains David Weissman, MD, director of palliative care at Medical College of Wisconsin/Froedtert Hospital, which is also home to a CAPC Palliative Care Leadership Center. However, six years ago when the virtual unit was launched, hospital beds were in short supply. So the hospital's administration made a counter-proposal: having a variable number of beds preferentially available for palliative care patients on 4-Northwest, a 22-bed internal medicine unit in the hospital.

Weissman calls this approach a virtual unit because the palliative care service doesn't have responsibility for management, staffing, or budgeting for a unit. Nor does it worry about keeping beds filled. However, Weissman's service is able to transfer palliative care patients within the hospital to 4NW and then draw upon a nursing staff that has volunteered for and received special training in palliative care. Reflecting its academic mission, the palliative care service at Froedtert does not assume primary medical responsibility for patients, preferring for the attending service to remain involved. "But we are an automatic consult," he explains. In some other hospitals, a virtual unit can refer to a palliative care team that floats to scattered beds throughout the hospital as needed.

"At first, we were concerned about mixing the two populations of patients," and how the nurses would respond to the challenges of wearing two different hats on the same day, Weissman says. "When we started, I was not convinced that it would work. But these nurses felt that they had a mission to do palliative care, just as they had taken on the mission of providing specialized care for sickle cell patients on the unit."

Best Nursing Team
In fact, 4NW was recently honored as Best Nursing Team of 2007 by the magazine Advances for Nurses, covering greater Chicago, Wisconsin and Indiana. The team was singled out for never backing down from a challenge, for piloting a new bar-coding system for the entire hospital, for its emphasis on shared governance, and for its commitment to sickle cell and palliative care patients. What may be surprising is how the nurses have taken to palliative care.

All of the nurses on 4NW have received two to three days of training in palliative care from nurse educators and the palliative care team, and a number have sought and earned certification in hospice and palliative nursing, says nurse manager Kim Coubal. Nurses on the unit have participated in providing palliative care education and Coubal tries to send several at a time to national palliative care-related conferences. New hires are made aware that palliative care will be part of their job.

The Internal Medicine/Palliative Care unit will always accommodate palliative care admissions, even if that requires bumping other patients from the unit, she adds. It has anywhere from zero to ten palliative care patients at a time, averaging two or three.

"The nurses can focus on quality of care and family support for their palliative patients, and then step back and take care of another patient who isn't dying," Coubal notes. "At the same time, they say it's not all 'doom-and-gloom' every day." Some of the nurses may have special skills with younger patients, or families with young children, or culturally diverse patients, and the team decides who will work best with each patient. Other patients transition to palliative care and a comfort-oriented approach while on the unit, and the nurses can help with that transition.

"It's a different kind of nursing," Coubal says. "Nurses who come to this unit stay on the unit. Our turnover rate was two percent last year, and I don't have problems with recruiting. Sometimes this can be extremely challenging work, but it's just not as stressful as doing palliative care full-time." In fact, Coubal says, the nurses are disappointed when they hear that they don't have any palliative care patients on their shift. "Our nurses would love to have more palliative care patients, but they are satisfied with the opportunities they get."

No Downsides
"We enjoy all the benefits of a dedicated space without the responsibilities of managing a unit," Weissman says. "I have no responsibility to fill beds, except that the nurses on 4NW are disappointed when the palliative care census gets too low. I don't have any administrative hassles. There really are no downsides to the virtual unit."

Weissman says he would not want to switch to his original vision of a dedicated palliative care unit. "This should not be thought of as a second-class alternative to having a unit." The virtual unit includes a family suite with extra room for families to stay over night, along with a kitchenette. "Amenities like that are nice, but what's really important is the people."

What is the trick to this approach? Weissman says the nurses who provide palliative care on 4NW get to practice the kind of pure, holistic nursing they went to nursing school to learn. "We help to give them recognition for the work they do, and they've given us their loyalty and incredible compassion."

Weissman concludes: "People need to have a sense of purpose in their jobs. I think that any unit where you find this level of sharing and strong, collaborative relationships between medical and nursing staff, you'll see similar outcomes."

"We enjoy the support of the palliative care team and
24-hour access to their expertise," Coubal adds. Palliative care team meetings are held on the unit. "We are always working on building the relationship." The presence of the virtual palliative care unit can be a great tool for recruitment and retention of nursing staff on medical/surgical units, she says. "This is a unit of people who like medicine, but palliative care is their love."

We enjoy the support of the palliative care team and
24-hour access to their expertise," Coubal adds. Palliative care team meetings are held on the unit. "We are always working on building the relationship." The presence of the virtual palliative care unit can be a great tool for recruitment and retention of nursing staff on medical/surgical units, she says. "This is a unit of people who like medicine, but palliative care is their love."

Note: David Weissman, MD will hold a CAPC audio conference on the topic of the virtual unit on Wednesday, March 19, 2008. It will be part I of a two-part series exploring the benefits of virtual and fixed units. Stay tuned for more information.

¹ For a discussion of the issues at stake and some programs' responses to them, see "Palliative care in inpatient units," by Diane Meier and Larry Beresford, in the December 2006 issue of the Journal of Palliative Medicine, 9 (6): 1244-1249.

Abstracts submitted for a unique poster session held at the 2007 CAPC Level II Seminar are featured in the "Notes from the Field" section of the October 2007 issue of Journal of Palliative Medicine. The focus of the poster session was "Innovative Solutions to Program Challenges."

You can also access the posters on the CAPC website at "Online Poster Session." This is the newest feature of CAPCconnect^SM, the platform where you, the palliative care community, can get informed, interact with colleagues and begin to put into practice what you learn from others.

Click here to visit "Online Poster Session"

Attend any one of six Palliative Care Leadership Centers^SM (PCLC) and secure your success with yearlong mentoring and two days of intensive training tailored to your institution.

Lock-in 2007 tuition rates:

1. Start your application by January 15, 2008
2. Complete your application by March 1, 2008

To learn more and register, visit www.capc.org/pclc

Early 2008 Palliative Care Leadership Centers^SM (PCLC) training dates are now available. To learn more about PCLC and which program is right for you, click here.

We encourage you to register soon, while sessions are still available. CME credits are available for physicians.

Fairview Health System - Minneapolis, MN
January 16-18
April 23-25

Medical College of Wisconsin - Milwaukee, WI
February 20-22
April 21-23
June 25-27

Mount Carmel Health System - Columbus, OH
January 31-February 1
April 3-4
September 11-12
November 6-7

Palliative Care Center of the Bluegrass - Lexington, KY
January 16-18
February 13-15
March 26-28
April 16-18
May 7-9
June 11-13
August 13-15
September 24-26
October 1-3
November 5-7

University of California, San Francisco -
San Francisco, CA
June 5-6

VCU Massey Cancer Center - Richmond, VA
March 17-18
May 19-20
September 15-16
November 10-11

To learn more and register, visit www.capc.org/pclc

Annals of Internal Medicine, November 20, 2007, Volume 147, Issue 10, pages 730-731: Coordinating Care: A Major (Unreimbursed) Task of Primary Care, by Thomas Bodenheimer, MD.

Annals of Internal Medicine, November 20, 2007, Volume 147, Issue 10, pages 693-698: How Much Time Do Physicians Spend Providing Care Outside of Office Visits?, by Jeffrey Farber, MD; Albert Siu, MD, MSPH and Patricia Bloom, MD.

National Association of Public Hospitals and Health Systems, December 1, 2007, Volume 21, No. 3: The Safety Net.

Oncology Times, October 10, 2007, Volume 29, No. 19: Hospice & Palliative Care Becoming More Integrated into US Health System, by Heather Lindsay.

Science Daily, November 2, 2007: Don't Tell Mother She Has Cancer.

The Journal of the American Medical Association, September 19, 2007, Volume 298, No. 11: Hospitals Embrace Palliative Care, by Bridget M. Kuehn.

The National Hospice and Palliative Care Organization (NHPCO) recently launched Partnering for Children, a national campaign to increase awareness of compassionate healthcare for children with life-threatening conditions and their families. The campaign is reaching out to parents, healthcare professionals, the media, and funders about the benefits of palliative care and hospice. Partnering for Children is a collaborative effort between the Children's Hospice and Palliative Care Coalition (CHPCC), the National Hospice and Palliative Care Organization and the National Hospice Foundation (NHF).

To learn more, visit www.partneringforchildren.org

Limited quantities of the CAPC Level II Seminar interactive multi-media CD-ROMs (audio, video, MP3, PowerPoint presentations) and audio-only CDs are currently available at the CAPC eMarketplace. These CDs feature Dr. Diane Meier's opening session and the four plenary sessions.

To learn more and make a purchase, visit the CAPC eMarketplace

Get 2 copies of A Guide to Building a Hospital-Based Palliative Care Program for the price of 1, during the CAPC Winter Sale! Known as The Guide, this comprehensive manual provides step-by-step guidance for building and managing a successful palliative care program. Covering topics that range from cultivating stakeholders and program planning to design, implementation, marketing, measurement and long-term sustainability, The Guide is perhaps the most important printed reference available for palliative care program development.

To take advantage of this special offer, visit the CAPC eMarketplace

Using Your Own Data:
Updating Your Business Plan to Ensure Sustainability
Thursday, January 24, 2008
1:30-2:30 PM Eastern

Dialogue with the Palliative Care Leadership Centers^SM Thursday, February 14, 2008
1:30-2:30 Eastern
FREE

Making change is all about making connection. CAPCconnect^SM is a new platform where you, the palliative care community, can get informed, interact with colleagues, and begin to put into practice what you learn from others.

The only forum dedicated to palliative care program development and growth!

The CAPCconnect^SM palliative care discussion forum is a free resource for health care professionals who want to share information, exchange ideas, and get advice from their colleagues on issues affecting their palliative care programs.

• Get feedback from other programs

• Hear from CAPC and PCLC faculty

• Benefit from peer-to-peer networking