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| How to Establish a Palliative Care Program | ||||
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Inpatient UnitsThe same forces that favor specialty units in general (eg coronary care units, medical intensive care units, spinal cord units, etc.) favor a dedicated unit for palliative care. Inpatient units provide expert clinical management to patients with severe symptom control problems, who are imminently dying or who cannot be managed in another setting. It is appropriate to admit a patient to a specialty unit when other settings are uncertain, untrained, uncomfortable, or unable to carry out the appropriate palliative care plan. Quality of care and consistent care plans are easier to ensure in dedicated units or when the patient or family desires the special environment and care. An inpatient unit can also be a site for interdisciplinary training, which complements consultation service or outpatient practice sites. Further, inpatient units offer an opportunity to pursue research protocols that require careful monitoring of patients. Many have a physical environment that distinguishes them from other parts of the hospital:
Palliative care units are organized in a variety of ways:
Inpatient units are distinguished by their scope of care, the orientation of the healthcare organization in which they are located, their source of funding, and their licensing. Licensing requirements vary considerably from state to state in terms of requirements and latitude under a given license. Nomenclature for the various types of units has not been standardized. Innovation to meet the particular needs of distinct communities is constantly producing hybrids and new approaches. The following list is meant to characterize the breadth of inpatient unit models that exist. Acute Palliative Care Beds or Units are operated under the hospital license. There are no special rules that apply to these units outside of the rules that govern acute hospitals in general. Consequently, there are no constraints on the scope of care provided in these beds beyond those that constrain the hospital. For third-party payers, patients must meet their criteria for being in the acute care hospital. These units currently exist in both academic and community hospitals. Subacute Units in hospitals have been established in response to changes in Medicare reimbursement legislation. They are an example of post-acute care where the focus is on providing treatments for problems identified during acute hospitalization with a focus on short-term rehabilitation and discharge. Although palliative care can be delivered as part of care on a subacute unit, they are not usually used exclusively for palliative care because of a perceived conflict in overall goals under the reimbursement rules or philosophy governing the unit. Hospice units in hospitals have been established under a variety of arrangements. Beds may be located within a designated unit, scattered throughout the institution, or located within a more limited area of the hospital, such as an oncology unit. These are sometimes operated under the hospital's license and at other times under a hospice license. If the patient has elected the Medicare Hospice Benefit, then the hospice program must have professional responsibility for the patient's plan of care and care is reimbursed under a hospice inpatient fee schedule such as the general inpatient rate. Although any treatment is conceptually possible on a hospice unit, these are often characterized by limitations on technology and diagnostic testing. They are usually for short-term care. Nursing Home hospice or palliative care units also exist. Because of nursing home legislation that is focused on maintenance of function and prevention of premature death, nursing homes in some places have found that they face heightened scrutiny unless the patients have elected hospice care from a certified hospice program. For a hospice unit in a nursing home, scattered beds as well as specific units are possible, just as they are in a hospital, and a contract between the nursing home and the hospice program is required. In addition, under the Medicare Hospice Benefit, a hospice program may provide routine home care or continuous home care services to patients as the facility is considered to be their home. In all instances, the hospice program must retain the professional management responsibility for the patient. Freestanding hospice units have also been established by hospice programs in many places. A variety of licensing arrangements are used based on what is available within a specific state. In order for the Medicare Hospice Benefit to be used for patients in these facilities, the hospice program must be Medicare-certified. A variety of relationships between these freestanding hospice units and hospitals exist, including the provision by a hospital of certain services not available on site in the freestanding unit. Freestanding hospice facilities may provide care at three different levels: general inpatient care, respite care and residential care. Some facilities provide only one level of care. The more typical arrangement is to provide all three levels. A residential hospice is the image that many people have when they hear the word hospice-a place to go to live the last days, weeks, and months of one's life. While residential hospices are still few in number in the US, they are increasing. Hospice programs who have a residential unit have become quite creative in developing a variety of funding sources, including Medicare Hospice Benefit routine home care payments. Medicaid payments under programs specific to a state, managed care and other commercial insurance arrangements, private pay on a sliding scale and philanthropy are also used. Those freestanding hospice facilities that provide only residential care need to have arrangements to provide symptom management services for patients whose acuity level rises. Some residential hospices provide symptom management by intensifying the staffing or by transferring the patient to a hospital or other setting. You can read more about developing an inpatient unit. CAPC Resources:
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