Palliative Care: Building a Sustainable Program for the Future (325)

Abstract

Objectives 1. Describe strategies for engaging palliative and similar supportive care at earlier stages of illness in an ambulatory setting for patients with advanced illness. 2. Determine how current, existing, supportive care services such as care-coordination, palliative care, and advance care planning might be reorganized to a more effective full continuum supportive care model for patients with advanced illness. 3. List new clinical processes that need to be put into place to make this model function. Palliative medicine has been an important addition to the care of patients with serious, chronic illness. Most commonly, this care is provided in acute care settings, often when patients are actively dying. While not a mature practice, there has been growing evidence of benefit of earlier palliative care introduction and comanagement of patients with advanced chronic illness. This development is occurring alongside other national trends such as care coordination and medical homes, which all seek to improve patient care by improving navigation and patient centered care across care settings. Gundersen Lutheran Health System has been approved by CMS to undertake a demonstration project to test the effectiveness of a new model of care for patients with advanced illness, where an integrated service line of palliative care, care coordination, and hospice care are introduced up to 18-24 months prior to death. This model was developed by reorganizing these well established services, with the process addition of a new in depth advance care planning tool called the disease specific patient centered advance care planning intervention. These three elements are brought together as a functional service called Advanced Disease Coordination (ADC). The goal of ADC is systematic, early identification of eligible patients; indepth and early care planning; and the coordination of care of patients with advance disease across care settingsdmost often while still receiving other medical treatments and well before decisions are faced about hospice. The goal of this service is to provide high quality care, consistent with an individualized care plan a crossed all settings of care. In this presentation the authors will describe: the historic and medical background that helped support this approach, the distinct services provided to the patients, how patients are identified and recruited, and some of the preliminary findings of the project.