Palliative care programs help challenging groups

Homeless, poor, and chronic conditions addressed

(Editor's note: This is the second of two-part series about best practices in palliative care programs. Last month we looked at an overview of three palliative care programs that were awarded the Circle of Life Award: Celebrating Innovation in End-of-Life Care by the American Hospital Association. We also examined the use of research to develop best practice and establish benchmarks. This month, we look at special programs to address challenging populations, including patients with chronic disease.)

Home health and hospice employees are accustomed to seeing patients in a variety of settings, but the staff of the palliative care program at Wishard Health Services in Indianapolis provide care for some of the poorest patients in their geographical area.

"We may initially see the patient in a hospital clinic, but when we visit them in the community, we may find out that they have no home," says Gregory Gramelspacher, MD, professor of medicine at Indiana University and director of Wishard Health Services Palliative Care Program. "Even if they have a place to stay, it may not be clean, have utilities, or even have furnishings," he says.

Because Wishard's management has made a commitment to serve the community, Gramelspacher's staff looks for ways to provide the best care for patients while respecting their wishes at the same time. "We do have agreements with local inpatient hospices to take patients who may not have a home," he says. "But, not all patients want to go into an inpatient facility." When a patient doesn't want to leave the place he or she calls home, social workers and chaplains will work to find services that can support the patient in the community.

Although the palliative care team doesn't force a patient into hospice care, all members of the team make sure patients understand the benefits of hospice care, says Gramelspacher. "We do make sure they have the opportunity to complete advanced directives and when they do decide to enter hospice, our patients tend to be admitted earlier in the process so they receive the best care possible," he adds.

Home health agencies have implemented chronic care programs to better care for patients with chronic diseases, but a chronic care program also can be beneficial for hospice patients, says John Morris, MD, medical director of palliative care and vice president of clinical outreach for Four Seasons, a hospice and palliative care agency in Flat Rock, NC.

Although a hospice patient might be dying from a disease other than a chronic condition, it still is important to understand the chronic disease and how to treat symptoms that might exacerbate pain or discomfort, says Morris. His agency implemented a chronic care program to provide specialized care to patients with cardiac conditions and chronic obstructive pulmonary disease.

"Staff members are trained in the use of diuretics, evaluation of chest pain, and protocols that best manage symptoms of patients with chronic conditions," says Morris. Because a patient with a cardiac problem might have symptoms not related to the reason for hospice admission, it is important to continue to manage those symptoms, he explains. "This program gives cardiologists confidence that their patients will receive the best care for all of their symptoms," he adds.

Because hospice's goal is to provide the best quality of life at the end of life, no one can ignore the symptoms of a chronic condition and treat the patient as if there were only one diagnosis, says Morris. "We need to get away from treating all hospice patients the same," he says.