TriCentral PC Toolkit : Chapter 2: Understanding Palliative Care and the TriCentral PC Program : Core components of the TriCentral Palliative Care Program

Palliative care programs vary one from the other. Some are dedicated inpatient units within a medical center, others refer to healthcare teams that perform pain consults, and still others, like ours, are outpatient programs that target the homebound. Patient eligibility, staffing patterns, the types of services offered — all these program aspects are variables that each staff must decide upon. Ultimately, these decisions define the program.

In our experience, the TCPC Program is defined by core features that work together in a particular way to achieve certain outcomes — among them, high patient and family satisfaction and cost-effective care. If you eliminate one or more core components or make substantially different substitutions, then your program may not achieve the same outcomes. Thus, for best results, the program's core components must remain intact, without modification. At the same time, you can modify virtually any other aspect of the program to suit the needs of your healthcare organization and its patients without compromising outcomes.

The core components of the TCPC Program are as follows.

The patient and family comprise the unit of care.
An interdisciplinary team directs and provides care. Core team members are the patient and family plus a physician, nurse, and social worker.
The team's health providers assess the physical, medical, psychological, social and spiritual needs of the patient and family.
Based on the assessment, the team develops a plan of care to provide coordinated care that emphasizes supportive services.
Home care is emphasized. Personal care services are available to support the patient and family. If needed, community-based services such as Meals-on-Wheels and In-Home Supportive Services are sought to help fill gaps in personal and home care.
Pain and other symptom management is emphasized.
- Comprehensive primary care is provided to manage underlying conditions with the goal of preventing acute exacerbation.
- Aggressive treatment of an acute exacerbation of illness is provided at the patient's or family's request.
Inpatient services are provided, when necessary, to ensure both appropriateness of care and continuity of care for patients who cannot be managed at home because of acute complications or because their family cannot manage terminal care for them at home.
Telephone support via a toll-free number and after-hours home visits are available 24 hours a day, seven days a week as needed by the patient.
Volunteers help provide support and assistance to patients and families.
Bereavement services are provided to help the family cope with social and emotional needs following the death of the patient.

Chapter 4, which presents procedures for the TCPC Program, describes in more detail how these core components are implemented.

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For more information about the TriCentral Palliative Care Toolkit visit www.growthhouse.org/palliative/. All content is Copyright © 2002, 2003 by Richard D. Brumley, M.D. All rights reserved. No part of this toolkit may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission from the publishers. This guide to developing home-based outpatient palliative care services was developed through a grant to the Kaiser Permanente TriCentral Service Area from The Project on Death In America. The Kaiser Permanente TriCentral Palliative Care Program is a Sustaining Member of the Inter-Institutional Collaborating Network On End-of-life Care (IICN) which links major organizations internationally.