Integrating Palliative Care Medicine into Skilled Nursing and Long Term Care

Topic: Palliative Care Models by Setting


Sentara2 Intergrating PC.jpg

Aim: to determine the impact of providing continuity for Palliative Care Medicine (PCM) from the inpatient setting to skilled nursing (SNF) and long-term care facilities (LTC).

Intervention: A full time PCM Nurse Practitioner (NP) was hired to change the static care model of discharge without continuity to a dynamic state.  This allowed for the PCM NP to unfreeze the current system and promote continuity between the inpatient setting and SNF and LTC facilities.  Spragen’s software was used to capture data based on the CAPC rounding tool.

Results: A favorable trend on the impact of daily ESAS screening was observed.  The avoidance of nine 30 day hospital readmissions, 13 admissions, 19 hospice referrals and 15 deaths followed by PCM resulted in decreased mortality within the hospital over a span of 5 months. Based on the impact of this initiative, the healthcare system is investing in replicating this model in other hospitals.

Conclusion:  Results suggest that PCM has had a positive impact on providing continuity and symptom management, resulting in a decrease in unnecessary hospital transfers, decrease in hospital mortality and improved patient outcomes.  Further studies are needed to validate findings.


  • Carol D. Miller, NP
  • Sentara Medical Group Palliative Care Medicine
  • 826 Jerryville Street
  • Chesapeake, VA 23322


  • Denise Miller, MSN, FNP
  • Donna Baldassare, DO
  • Francina Singer, LCSW
  • Mary Trosien, MSN, FNP
  • Parag Bharadwaj, MD
  • Susan Reutzel, MSN, FNP

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