Patients who are referred to the Palliative Care Division are managed in a model of care designed to ensure that patient needs are matched to the appropriate services throughout the course of the disease (view the model). Inpatients at the Petrie Division of Beth Israel Medical Center are referred to the Department's consultation team. Outpatients are referred to a physician in the Department's ambulatory practice. Continuum Hospice Care, which is administered by the Palliative Care Division, can also receive direct referrals of patients who meet criteria for a hospice program referral. Inpatients or outpatients who are referred to the Department's physicians include patients who are referred specifically to facilitate a transfer to the hospice program, and those patients who are not appropriate for hospice and are referred for a variety of reasons (e.g., poorly controlled symptoms, the need for a comprehensive palliative care approach, or specific issues related to the imminently dying). The non-hospice palliative care patients, whether inpatient or outpatient, can be broadly divided into two categories. Some patients have limited needs and can be managed in a traditional physician-based approach. Ambulatory patients of this type are usually followed through periodic office visits. Non-hospice palliative care patients with more extensive needs are managed in a nurse/social worker-directed case management approach. The initial evaluation for these patients often involves the physician, nurse, social worker, and possibly other members of the palliative care team. All patient cases are discussed at a weekly meeting where decisions are made about the best type of care that might be offered the patient. Patients who are already in the practice and are having active problems also are discussed. The services offered to the patient can be changed as needed to optimize care within the resources available to the Department and to the patient and family. Patients who are followed for a period of time may become candidates for referral to the hospice program. Hospice is viewed as a wonderful resource for providing comprehensive services for patients with advanced illness who are no longer receiving aggressive disease-oriented therapies. Patients may be referred to the hospice program by the physician, by the nurse or social worker in consultation with the physician, or by appropriate individuals in the home care nursing agency or long-term care facility. Patients who elect admission to the hospice program are provided a range of services. The program has a weekly interdisciplinary team meeting, at which patients are discussed and the care plan changed as necessary. The hospice program provides access to nurses, psychosocial support, chaplaincy services, volunteers, and other services. Occasionally, patients who have elected the hospice program must withdraw from it. In contrast to the situation in other settings, patients in our model can return to the case management approach and have continuity of care provided by the physician and others in the team. The Department of Pain Medicine and Palliative Care maintains an 18-bed inpatient pain and palliative care unit. Hospice patients who meet criteria for an inpatient stay, non-hospice palliative care patients with acute medical problems, and highly selected patients with chronic pain may all be admitted to the unit under the direction of an attending physician in the Department. Non-hospice palliative care patients who are admitted may use this event to change the type of care provided after discharge by electing hospice, if appropriate, during the admission. The family, broadly defined, is considered the unit of care in palliative care. Caregivers may be offered support in a variety of ways while the patient is being treated either within the hospice program or within the broader model of palliative care. If a patient who has elected hospice dies, the caregivers will be provided access to a bereavement program. Over time, bereavement services will be expanded to the caregivers of non-hospice palliative care patients as well. Palliative Care Websites American Academy of Hospice and Palliative Medicine American Board of Hospice and Palliative Medicine Continuum Hospice Care End-of-Life Physician Education Resource Center European Association for Palliative Care Growth House, Inc. Hospice Cares International Hospice Institute & College National Hospice and Palliative Care Organization U.S. Dept. of Health and Human Services: A Clinical Guide on Supportive and Palliative Care for People with HIV/AIDS, 2003 Need more information on palliative care? Ask a question?

Department of Pain Medicine and Palliative Care Beth Israel Medical Center, New York City ©2005 Continuum Health Partners, Inc. www.stoppain.org/palliative_care