Patient and family services include ongoing care provided by all members of the IDT, after-hours services, and inpatient care. Also available are medical supplies, durable medical equipment, oxygen, and medications.
The palliative care physician visits the patient at home within a week of admission, with follow-up visits every 4-8 weeks or as needed. The physician will make more frequent visits if medically necessary or if a patient evaluation is needed.
Physician services include, but are not limited to: evaluation and management of the patient's medical condition, including pain and other symptom control. The palliative care physician discusses with the patient advance care plans and treatment goals. He or she also ensures that consensus about care is reached between specialists and other physicians involved in the patient's care.
Skilled nursing services are provided by or under the supervision of a registered nurse, in accordance with the patient's plan of care. An IDT nurse visits the patient at home as often as required by the patient. Typically, this means 2-3 weekly visits during the first few weeks in order to establish a strong relationship with the patient and help him or her manage care at home. The nurse may visit less frequently thereafter, but never less frequently than every other week unless the patient's condition stabilizes. The IDT must approve visits that are less frequent than every other week. More frequent visits may again be needed in the few weeks before death as patient and family needs for bio-psychosocial support increase.
Skilled nursing services include, but are not limited to: patient assessment, evaluation and care management of the medical nursing needs of the patient, the performance of prescribed medical treatment of pain and symptom control, the provision of emotional support to both the patient and his or her family, and the instruction of caregivers in providing personal care to the patient. Skilled nursing services are available on a 24-hour on-call basis.
Social workers provide counseling and emotional support to help patients and their families address their economic, psychosocial, and spiritual needs. An IDT social worker completes an initial assessment of the patient and family within one week of admission. Thereafter the social worker conducts either a telephone consultation or an in-home visit at least monthly and more often if necessary.
Social work services include, but are not limited to: psychosocial assessment of the patient and family, counseling to help the patient and family cope with the stress of terminal illness, assistance in planning care, and coordination of community resources.
The following services are available as needed by the patient and family. The core team assesses need for adjunct services and arranges for and coordinates these services from the appropriate providers.
Certified staff members provide personal care services to help patients maintain personal hygiene and remain comfortable at home. Their services also help secure a safe, healthy environment for patients. Services, including bathing, grooming, meal preparation, shopping, and other related activities, are provided under the direction and supervision of a registered nurse.
Provided by a spiritual counselor or chaplain at the patient's request, these services help patients and families sustain hope and cope with the changes taking place. The counselor or chaplain helps the patient and family integrate the dying experience into their lives, find meaning and purpose in what remains of life, and further their appreciation of spiritual values or sacred values associated with their belief system. This service is available to all patients and families regardless of their spiritual or religious affiliation. The spiritual counselor or chaplain also is available for bereavement counseling and to conduct funerals or memorial services.
These services include physical therapy, occupational therapy, and speech therapy. Services are provided for symptom control and to enable the patient to maintain activities of daily living and basic functional skills that promote physical and psychosocial independence. These services are also aimed at improving restorative function, home safety, and the patient's transfer skills.
Patients often have co-morbid conditions that require multiple medications. Kaiser pharmacists serve as experts to the IDT, offering guidance for managing complex medication regimes so that adverse medication events are avoided and pain and other symptom control is achieved. Less frequently, pharmacists will consult directly with patients as needed to help them manage their medications.
Many patients experience symptoms and medication and treatment side effects that negatively affect their nutritional status. A dietitian is available to provide expert consultation to the IDT so that team members can educate the patient and family about innovative yet practical dietary interventions that enhance comfort and nutritional satisfaction. Less commonly, the dietitian provides these same services directly to the patient and family.
Bereavement counselors offer these services to the surviving family members for a period of at least one year after the death of the patient. Typically the bereavement counselor is the same IDT social worker who was originally assigned to the patient and family so that continuity of care is maintained. Services include an assessment of the family's needs and development of a care plan to meet those needs, both prior to and following the death of the patient. Other services available are bereavement support meetings, individual counseling, follow-up telephone calls, empathy cards, and newsletters. Information and referrals to appropriate community resources are also offered.
Program volunteers, working under the supervision of TCPC staff, provide support and companionship to patients and their families. They also provide respite care, staying with the patient so that caregivers can have time off. Following the patient's death, volunteers offer bereavement support to the surviving family members. All volunteers receive training from TCPC staff prior to providing services.
As advanced illness is not time bound, 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 and his or her family. Palliative care registered nurses manage these after-hours services, providing guidance based on established treatment guidelines, obtaining physician orders, arranging for prescription medications, and providing other services as needed based on a telephone assessment of the patient and family. Palliative care physicians are also available 24/7 to support patients and their families as well as the after-hours staff.
All after-hours telephone interactions with patients and families are documented and placed in the patient's medical record. The nurses relay information from these calls to the IDT and follow-up with patients and the family as needed
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.
Inpatient care is provided at the least-acute level that can provide necessary treatment in accordance with the patient's plan of care. If possible, inpatient care is delivered in a non-acute setting such as a skilled nursing facility or a hospice-like inpatient unit. Following a necessary acute care admission, the patient is transferred to a non-acute setting as soon as possible when consistent with the patient's preference and treatment goals. Inpatient terminal care is available as needed, generally for ten days or less, if possible.
Medical supplies, durable medical equipment (DME), oxygen, and medications are all available to patients as needed, 24 hours a day, seven days a week. Medical supplies, DME, and oxygen are provided based on the patient's Health Plan benefit. Prescriptions are provided under the patient's Health Plan prescription drug benefit.
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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.
