Hospital and Program Description

: Gundersen Lutheran Medical Center is a tertiary care hospital, serving a predominantly rural Midwestern community. The existing Palliative Care service consisted of a solo APN with MD backup, with consultation inpatient or outpatient as an adjunctive service.

Problem

Fragmentation of care. Patients progressing through late stages of illness were seen by multiple providers from different specialties, and lost a unifying presence from their primary care provider. This resulted in poor communication and poor continuity of care at end of life.

Processes to resolve problem

Creation of a novel palliative care primary service, staffed by internists/hospitalists, along with an APN and inpatient hospice team. The service provided consultation on patients with advanced illness and limited curative options, with ability to provide symptom control, clarify goals of care, and subsequent primary care in the hospital, including an inpatient hospice option for actively dying patients. We further established an outpatient presence to promote continuity, with 24/7 availability for emergent issues. Available outpatient services included home visits, clinic visits, and urgent re-hospitalization.

Outcomes

The palliative inpatient team received almost 600 consults in its first year, and provided subsequent primary care for 75% of these patients. Patient and family satisfaction, readmission rate, cost per hospitalization and hospice referral were all positively impacted by the new service, with high physician/staff satisfaction noted as well.

Lessons Learned

The combination of Palliative and Hospital Medicine may present a viable form of primary care for the last years of life. The presence of both medical expertise and holistic focus within the same team, with a willingness to provide care across medical settings, offers a h3 alternative to the traditional specialty driven and fragmented medical model which defines care for patients in this country in the last years of life.