Collaboration — and coordination of care — is the future of health care

Hospices use innovative approaches to work with others

The current focus in federal health policy on coordinating patients' health care throughout the entire continuum of care has resulted in promotion of Accountable Care Organizations (ACO), Medical Homes, and Integrated Delivery Networks. Although no one can predict what the final rule from the Centers for Medicare and Medicaid Services (CMS) governing ACOs will look like, everyone agrees that improved coordination and communication among providers is a good thing for patients.

"Hospice providers will play an important part in ACOs and we are aligning ourselves with other providers who are likely to be key drivers in ACOs," says Flint Besecker, chief executive officer of the Center for Hospice and Palliative Care in Cheektowaga, NY. His organization was a winner of the American Hospital Association's 2011 Circle of Life Award®, presented for innovation in end-of-life care. A key reason for the hospice's award is a history of collaboration with other providers and people in the community to expand services to a wider range of patients.

There is a natural psychological barrier for patients and families when considering a decision to choose hospice, points out Besecker. Although his organization went through several years of presenting itself as a "symptom management" organization to make hospice seem less threatening, people still think of hospice as a place to die if you don't have an opportunity to educate them, he adds. "We've found the best strategy is to recognize the psychological barrier and find ways to reach patients before you are talking to them about hospice," he says.

By partnering with physician practices that provide oncology, nephrology, and cardiology services, Besecker's staff can provide palliative care services to manage symptoms that are not directly related to the disease for which the patient is being treated. "A great benefit to the physician and the patient is the availability of our palliative care nurse practitioner or physician to make house calls to evaluate the patient's pain, shortness of breath, or other symptoms outside office hours," he points out. "Typically, a patient who calls to complain of pain in the evening or on weekends is sent to the emergency department," he explains. The additional support of a clinician, who can make house calls, enables the patient to stay home in most cases.

"We also offer psychosocial services that the physician does not have to offer patients," says Besecker. "Physicians see us as a value-added service for their practices and we get an opportunity to educate patients as their disease progresses," he says. By establishing a relationship with patients while they are receiving treatment, staff members can introduce the concept of hospice when appropriate, he says. "Our staff is comfortable having these tough conversations and can help patients and their families evaluate their options," he says. Because patients have a relationship with the hospice staff member who has provided palliative care, they are often receptive to the conversation and will often enter hospice care earlier than they might have before, he points out. "If we can get patients into hospice earlier rather than the last 7 to 14 days of life, we can positively impact their comfort and quality of life for them and their families," he adds.

In addition to the physician practices with which his hospice currently partners, they are working on agreements with a geriatrics practice, among others, says Besecker. The key to his hospice's success is that they've recognized that not all physicians see the value of palliative care, he points out. "We talk with a physician to see if we are a fit for each other," he says. "We don't want to impose our philosophy on a physician's practice but we do want to work with physicians who share our goals of providing the best care for patients," he adds. If a physician seems reticent or unsure, don't waste your time trying to talk him or her into a partnership, he recommends. "Spend your time where you are wanted."

Gilchrist Hospice Care in Hunt Valley, MD, another winner of the 2011 Circle of Life Award, also was recognized for its patient-centered care that coordinates and provides patient care in multiple settings. The hospice, an affiliate of Greater Baltimore Medical Center, was opened in 1994 and over the years the hospital system added palliative care, geriatric medicine, and senior services. Although the different services communicated with each other to coordinate care, they were all combined into Gilchrist Greater Living in 2010.

"We have staff members providing services in acute inpatient settings, the patients' homes, assisted-living and long-term care facilities," says Cathy Hamel, vice president of post acute care services for the hospital system and executive director of the hospice. "Our field staff specializes in different areas because each setting requires us to do our work a little differently," she explains. Even though hospice and palliative care staff members may focus only on one setting, the continuity of care is there because everyone uses the same practice guidelines and standards of care, she says. "We've also standardized our handoffs to include two-way conversations rather than one-way methods of communicating, such as written notes or voicemails," she adds. "Also, each of our staff members has access to all electronic medical records." This gives staff members the opportunity to see the patients' records from all care received in different settings of the health care system. "Long-term care facilities' records are usually not automated and we work with facilities that are not part of the same system so staff members in those settings need to work with the facility staff to review the patients' records when necessary," she adds.

Care conferences, which are routine and expected as a Medicare Condition of Participation for hospices, are utilized in all settings, even long-term care facilities, points out Hamel. "These conferences are well received by the long-term care staff," she says. "They appreciate the effort to bring people together to discuss a patient's care." The interdisciplinary conferences can differ from setting to setting, she points out. "If we have several patients in one facility, we'll gather in a meeting room to discuss all of the patients, but if we only have one patient in the facility, we may hold the conference bedside," she explains. The most important focus is improving communication between all members of the patient's care team, she adds.

Gilchrist Hospice also offers Expanded Services, which is a program that provides services that are not part of the hospice benefit but are requested by the family or patient, says Hamel. "These are families who need a little more time to make the decision to stop curative treatment and enter hospice," she says. "For example, a patient may be receiving nutritional support but wants to enter hospice," she says. Because the Medicare hospice benefit does not cover nutritional support, Hamel's staff may agree to provide the service as the staff counsels the patient and family. "This provides a more gradual passage to hospice," she explains.

Although Medicare does not cover services such as nutritional support for hospice patients, some third party payers do cover some expanded services, says Hamel. "Hospice fundraising covers the non-covered expenses," she adds.

Hamel's organization is interested in the proposed Concurrent Care Demonstration Project that is included in Patient Protection and Affordable Care Act. "By offering expanded services now, we are positioned to participate in the project when it is announced," says Hamel. "Offering patients a more gradual transition to hospice will result in more people entering hospice sooner and being able to die with dignity."

With the movement toward more collaborative care across the health care continuum, Hamel believes that hospices are well positioned to be an important part of the new focus on communication. "We are already good at working with a variety of clinicians, patients, families, and settings, and we have a lot of experience to bring to the table," she explains. "This is a very exciting time for hospice providers to reach out and collaborate with other providers."


For more information about community collaboration, contact:

• Flint Besecker, Chief Executive Officer, The Center for Hospice & Palliative Care, 225 Como Park Blvd., Cheektowaga, NY 14227-1480. Tel: (716) 686-1900; fax: (716) 686-8181; e-mail:

• Cathy Hamel, Vice President of Post Acute Services at Greater Baltimore Medical Center and Executive Director of Gilchrist Hospice, 11311 McCormick Rd., Suite 350, Hunt Valley, MD 21031. Tel: (443) 849-8200; e-mail: