TriCentral PC Toolkit : Chapter 4: TriCentral Palliative Care Program Operations : Patient Enrollment

1. Has a life threatening illness — typically cancer, congestive heart failure (CHF), or chronic obstructive pulmonary disease (COPD) — with an expected prognosis of 12 months or less.

2. Is homebound, requiring a considerable and taxing effort to leave.

3. Has a deteriorating medical condition and is at risk for needing symptom management. The patient may have had 1-2 Emergency Department or hospital admissions in the last year.

4. Has a primary care person available to provide care, or to ensure that an appropriate caregiver is available to provide care when necessary.

5. Agrees with the emphasis of care in the home setting with short-term inpatient care limited to: (a) symptom control not obtainable at home, or (b) care through the terminal event. More aggressive therapy, if appropriate, may be provided by the primary physician in another care setting.

6. Does not meet hospice admission criteria for one or more of the following reasons: (a) Patient/family have difficulty accepting the life-threatening diagnosis and prognosis, (b) Patient/family are not agreeable to stopping aggressive therapy, and/or (c) The primary physician is uncertain if patient meets the hospice admission criteria.

7. Scores 7 or less on the Palliative Performance Scale, which provides an assessment of the patient's functional status while measuring the progressive decline in the person's health (see the Appendix for a copy).

Palliative care patients may be receiving potentially curative therapy at the time of their admission. Cancer patients may be receiving active chemotherapy treatments. Patients with CHF or COPD may report limitation of function on most days, for example, being able to walk no more than one block or climb no more than a flight of stairs.

1. A hospice/palliative care intake nurse (RN) conducts the initial screening of patients by telephone or in-person using the program's screening tool (presented in the Appendix).

2. A palliative care nurse who is a member of the IDT completes the initial assessment of a new patient in the patient's home. This assessment includes:

• Review of the palliative care program
• Obtaining informed consent for admission
• Identification of patient and family goals
• Initiation of a new medical record
• Medical history review
• Physical assessment
• Medication review
• Advance care planning with discussion of patient preferences regarding Do Not Resuscitate (DNR) orders
• Home safety assessment
• Ordering any durable medical equipment needed by the patient
• Assessment of the patient/family's education and training needs
• Introduction of the IDT process and the core team members
• Initiating involvement of any adjunct team members needed by the patient or family
• Ensuring that a binder with the patient's medical records and plan of care is available in the patient's home for ongoing use and reference by IDT members.

3. Based on this assessment, the nurse, in conjunction with the IDT, develops a plan of care, which is reviewed, discussed, and revised as necessary within a week of the patient's admission.

4. The IDT informs all other physicians involved in the patient's care (i.e., the primary physician and any specialists) of the patient's admission to the TCPC Program.