Evolution in The United States
In the United States, early hospice services were provided almost exclusively in patients'
homes. The early US hospice movement was created outside of the established
health care system. In contrast with the United Kingdom, these teams were usually nurse and/or
volunteer led. This prevailing pattern was systematized in the
Medicare Hospice Benefit
legislation passed in 1982 and implemented in 1983.
Although there was an effort to mimic the British model of hospice with the founding
of the Connecticut Hospice in conjunction with Yale University in 1974, this did not change
predominant patterns.
The Medicare Hospice Benefit did recognize the need for hospice programs to have
access to inpatient facilities when the patient's needs couldn't be met at home. Many programs
realized that admitting patients to general units in hospitals and nursing homes made it more
challenging to assure implementation of the overall hospice plan of care. As few staff in these
institutions had palliative care training or expertise, some hospice programs chose to develop
dedicated hospice inpatient units to resolve these concerns.
More recently, palliative care consultation services started in the US as a therapeutic
approach with the same goals as hospice care but without the constraints. Most palliative
care services began as inpatient consultation services in hospitals and in ambulatory clinics.
These programs frequently link with one or more hospice programs as a means to extend care to
the home. In fact, hospice programs in conjunction with hospitals and healthcare systems may
develop them. The goal of these services is to make the insights and expertise originally
developed within hospice programs more readily available to patients in other parts of the
health care system.
In understanding the development of hospice and palliative care programs in the US, it is
useful to observe two things:
- The underlying health care system in the US is different from that in the UK. It is a
market-based, rather than a centrally planned system. Hospices in Great Britain grew up in
the context that every patient with cancer already has access to a general practitioner and a
skilled nurse who will make home visits. In contrast, hospice programs in the US were developed
where there is no such system.
- Hospice programs in the US were established in response to health services that failed to
provide comprehensive services for the dying. This circumstance led to hospice care being
defined as an alternative to, rather than a part of, the health care system. Consequently,
the hospice movement as a whole had a strong countercultural spirit based, in part, on
frustration with traditional systems of care.
While the terms "hospice" and "palliative care" both have
historical roots that vary regionally and nationally, there has
been a convergent evolution so that both "hospice"
and "palliative care" have evolved to describe the
same concept of care
Evolution in:
The United Kingdom
Canada
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CAPCManual Attribution:
von Gunten CF,
Ferris FD,
Portenoy RK,
Glajchen M, eds.
CAPCManual: How to Establish A Palliative Care Program.
New York, NY: Center to Advance Palliative Care, 2001.
©
Center for Palliative Studies, San Diego Hospice & Palliative Care, San Diego, CA
and
The Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, NY, 2001
Permission to reproduce for non-commercial educational purposes with display of
attribution and
copyright is granted.
Last updated: February 20, 2002
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Rationale
Select section:
Changing Illness Experience
Changing Expectations and Needs
Progressive Healthcare Response
Responding to the Opportunity
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Changing Illness Experience
Illness in the Past
Progress Fighting Disaese
Illness Today
Prolonged Illness Experience
Chronic Disease Process
Determining Prognosis
Cancer
Manifestations
Predicament
Prolonged End-of-life Experience
Sudden Unexpected Death
Predictable Decline
Slow Decline, Multiple Acute Crises
Death in the US
Leading Causes of Death
Setting of Death
Desired
Reality
Multiple Issues Cause Suffering
The Square of Care
Morbidity
Pain
Need for Assistance
Social, Financial Impact
Implications for Care
Variable Need for Care
Opportunities
For Patients
For Families
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Changing Expectations and Needs
Increased Consumer Autonomy
Picker Institute 8 Dimensions of Care
Goals, Not Problems, Drive Care
Shift to Goal-oriented Care
Expect Competence, Expertise
Expect Comprehensive Assessment
Expect Effective Communication
Expect Participation in Decision-making
Expect Timely, Continous, Coordinated Care Delivery
Expect Assistance with Caregiving
Caregiver Training, Support
Caregiver Financial Support
Alternate Settings of Care
Respite Relief
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Progressive Healthcare Response
Focus on Disease-modifying Therapy
Focus on Care of the Dying
Early Hospice
Modern Hospice Movement
Dame Cicely Saunders
Origins of "Palliative Care”
Evolution of Hospice, Palliative Care
In United Kingdom
In Canada
In United States
Convergent Evolution
Hospice, Palliative Care in US Today
Hospice Growth
Continued Unmet Opportunity
A Public Health Issue
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Responding to the Opportunity
Paradigm Shift in Thinking
Provide Concurrent Care
Consider Application to Those at Risk
Expand Services, Settings of Care
1º, 2º, 3º Model of Delivery
Expand Access to Expertise
Create Specialized Environments
Many Names, Same Focus of Care
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