Hospital & Program Description

Kaiser Foundation Hospital Fontana is a 400-bed, urban medical center serving over 350,000 members of Kaiser Permanente in San Bernardino County, California. Clinic-based Palliative Care shares a clinical social worker, two registered nurses and a physician with the In-Patient Palliative Service.

Problem

Patients with severe, life-threatening chronic conditions (e.g., congestive heart failure, chronic obstructive pulmonary disease, cancer) risk needless suffering in-between and during recurrent hospitalizations near the end of life.

Process to Resolve the Problem

Clinic-based Palliative Care provides telephonic care coordination, routine office visits, and same-day urgent visits for patients and families for symptom management, psychosocial support, advance planning, care coordination, and transition community-based care.

Outcomes:

Since its inception in 2004, Clinic-based Palliative Care has maintained an average daily census between 50 and 60. One-third of all patients transition out of the service each quarter (60% elect hospice or home based palliative care). Patients and families are able to clarify their goals of care and preferences regarding intensive treatments before the next crisis of care occurs. The key interventions include partnering with patients to enhance self-care skills and the availability of a rapid-response system to treat urgent concerns.

Lessons Learned:

Clinic-based Palliative Care fills the need of a select group of patients for symptom management and support as they continue to pursue intensive treatments. Anticipatory management of known high-risk situations also provides alternatives to recurrent hospitalizations for complications of severe-life-threatening chronic diseases.