Provide the right care
for each patient
at the right time
in the right care setting
Transitions in Care:
Caring for our Patients
Connecting our Partners
Jane Pike-Benton
Executive Vice President
Home Health & Care Transitions
Palliative Care Program - Mission
Multi-disciplinary approach to shift the culture of
our acute care facilities regarding serious illness and
end of life care
Our Journey
Fall 2009
May 2010
STAAR Team record review of readmitted HF patients
reveals multiple patients with chronic HF and end of life
MetroWest Medical Center Ethics Committee ask
MetroWest HomeCare & Hospice to collaborate to develop
an Inpatient Palliative Care Program
August 2010
Saint Vincent Hospital and MetroWest HomeCare &
Hospice team up to create a cross-continuum Inpatient
Palliative Care Program
Our Journey
Feb 2011
Inpatient Palliative Care Program begins consults at
April 2011
o Inpatient Palliative Care Program begins consults at SVH
Palliative Care Program Structure
Palliative Care Steering Committee
approves policies & procedures, physician order sets and
drives the cultural shift through education
Palliative Care Consult Team
meets with patients, family members and health care team
members to discuss patient wishes and options
Palliative Care Program Structure
Important to align the Palliative Care Program with the Ethics
Committee, Cancer Care Center, Intensive Care, Emergency
Department, Physicians, Hospitalists, Nursing and
Chaplaincy, as well as other care team members
Additional Responsibilities
Policies and Procedures
Physician Order Set
Education at Physician, Nursing and Administrative
Schwartz Rounds
Palliative Care Informational Fairs
Introduced in 1997 with
funding from a grant from the
Robert Wood Johnson
Changes the way we talk about
and plan for care at the end of
Simple to use
Available in 15 languages
Can also be completed on line
Hospital – Hospice Partnerships in Palliative Care
Benefits as per NHPCO
Enhance pain and symptom management
Care concordant with patient-family preferences
Improved patient and family satisfaction
Reduced costs via shorter length of stay, decreased
readmissions and less acute treatment ordering
Earlier transition of care to Bridge or Hospice care
Other Potential Benefits
Patients who are discharged savings- $1696
 Patients who die in the hospital savings - $4900
 Decreased readmission rate of patients with
chronic and/or end of life illness
Morrison et al published an article in The Archives of Internal Medicine
2008;168(16):1783-1790. “Cost Savings Associated with US Hospital Palliative
Care Consultation Programs”
Palliative Care Outcomes
169 consults completed
in the first 7 months
Many patients with chronic illness
unrelated to cancer
37% of patients were admitted from
Skilled Nursing Facilities
It’s about how you live
Center for Advancement of Palliative Care
Resource for tools, articles, templates for policies and
Five Wishes
NHPCO-National Hospice & Palliative Care Organization
Discussion & Reflection

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