Steps for creating an in-hospital program
A step-by-step approach
While hospices bring a wealth of palliative care expertise, they need to cooperate with their hospital partners as they go through the process of establishing an inpatient palliative care program. To provide direction to hospitals and hospices that are collaborating in establishing an inpatient program, the New York City-based Center to Advance Palliative Care (CAPC) has outlined the following step-by-step approach:
1. Identify institutional leaders and initiate a strategic planning process.
Strong, effective leadership is the key ingredient for successful development of palliative care programs. Identify key stakeholders and champions among the hospital/health system staff and from the community.
2. Conduct an institutional and community needs assessment for palliative care services.
Developing a new clinical service requires an organized process, convincing data, and demonstration of a compelling unmet patient need within the institution as well as the community. Begin this analysis by interviewing potential stakeholders. Assess their interest and needs. Elicit their support and identify opportunities for collaboration.
3. Survey the community for competitive palliative care services.
Specifically look at:
- length of time in operation;
- reputation and ability to meet patient needs;
- gaps in existing palliative care services;
- potential collaborative opportunities.
4. Profile hospital patient population and demonstrate an unmet patient need.
Look at the patient population that will benefit most from palliative care. For example, demonstrate the costs to the hospital for failing to institute appropriate services and discharge options for vulnerable, seriously ill patients, many of whom are dying. Graphically illustrate the scale of unmet patient need with data such as:
- total number of hospital deaths annually by age group and insurance status;
- causes of death by Medicare DRG;
- locations of deaths (e.g., medical/surgical unit, ER, ICU, etc.);
- length of stay in hospital and in ICU by DRG, among patients who die in the hospital;
- discharge information (destination);
- number of patients with advance directive, health care proxy, and/or DNR order.
5. Conduct focus groups.
Further define your patient population and its needs by convening several small focus groups to reveal additional reasons for instituting a palliative care program. Focus groups to convene include:
- physicians;
- nurses, social workers, pharmacists, and chaplains;
- patients in specific diagnostic groups;
- family and caregivers.
6. Develop a mission statement, goals, and objectives for the palliative care program.
With your research completed, develop a compelling mission statement and goals and objectives that reflect and reinforce unmet need. Establish short-term (12 months) and long-term (three years) program goals that are as specific and measurable as possible. Goals to consider include:
- patient/caregiver satisfaction;
- physician and staff satisfaction;
- growth in patient volume;
- financial performance;
- impact on length of stay in hospital and in ICU;
- innovation/research;
- awards/recognition.
7. Decide on the range of services to offer.
The range of palliative care services offered will depend on such variables as:
- gaps in existing community services;
- type of population to be cared for (e.g., complex tertiary-care referral populations vs. small community hospital populations of mostly elderly and chronically ill);
- location in the hospital where most patient deaths occur;
- inpatient hospital bed constraints.
8. Select a delivery model.
This can include a consultation service, a dedicated inpatient unit, a combined consultative and geographic unit model, a combined hospice palliative care unit (with or without a contract with a community hospice), or a hospital outpatient palliative care clinic. (For more information on these models, check out the CAPC web site at: www.capc.org.
9. Determine funding sources.
Medicare and Medicaid are the primary payers for palliative and hospice care. Medicare is the benchmark for rates paid by private insurers for these services.
10. Develop a public relations and communications plan.
Identify both internal and external audiences to whom you will promote the new service. Activities may include:
- program brochure and direct mail campaign;
- educational programs for referring physicians, families, and patients;
- local news and human interest stories;
- public relations and fundraising events.
11. Develop an operations plan.
Identify all the resources/costs required to put the program into operation, including:
- administration and management team;
- community advisory group;
- staffing;
- space renovation and rent;
capacity (number of beds/patients per staff unit);
- medical and office equipment and supplies;
- medical records;
- quality assurance;
- public relations/communications.
12. Develop a financial plan.
Using cost estimates from the operations plan, develop a financial plan including a three-year proposed program budget of revenues and expenses. Project estimated revenues from all funding sources, based on anticipated patient utilization and service volumes.
13. Recruit a skilled interdisciplinary team.
Once your program is approved, recruit a skilled interdisciplinary team from the outset. For a dedicated inpatient unit, the team should include a physician, a nurse, a social worker, and/or a bereavement or pastoral care counselor. If having a dedicated bereavement staff is not possible, the palliative care service should be able to refer families to affiliated bereavement program staff. Other experts who can make a significant contribution to the team include patient advocates, chaplains, pharmacists, pain experts, rehabilitation experts, and psychiatric consultants.
14. Develop a patient database to measure quality and outcomes.
Clinical data, patient and family assessments, and financial information should be collected in easily accessible and usable databases. It is also important to track and evaluate all program research and educational activities. Data such as these help quantify the importance of the program and are critical to demonstrating the program’s benefit to the hospital’s mission and reputation.
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