Sourcebook : 16.1 Offer Tailored End-of-Life Services to Patients with Advanced Heart or Lung Disease : 16.1.1 Case Study - Kaiser Permanente Bellflower

A Model for Integrated Health Care Services

The hospice model for care is based on integrated care delivery in which a multidisciplinary team works in concert to meet the diverse physical and psychosocial needs of dying patients. A similar model can be applied to end-of-life care for heart disease patients. A team at Kaiser Permanente Bellflower near San Diego developed a model among programs to improve care for patients with advanced heart disease.

The CHF Case Management Program at Kaiser Bellflower is an excellent model for others to follow in setting up care management programs for heart disease patients. In 1994, CHF was Kaiser Bellflower's third highest cause of hospital admission; in 1997, it was the seventeenth. The program has been expanded to cover the entire medical center.

Health care providers knew that fragmented care was not good for patients who experienced acute exacerbations of illness, saw many specialists, were frequently readmitted to acute hospitals and home health programs, and were seldom referred to hospice. (Of those who were, 26 percent died in their first week and 35 percent died in the next three weeks, limiting the time when hospice could provide supportive services for patients and families.)

A physician manager and case manager/nurse developed a program to improve care for heart disease patients. The program focused on four aims:

• Achieving an optimum quality of life for patients
• Providing patients with excellent care
• Preventing recurrent hospitalization and ER visits for CHF patients
• Helping to provide good end-of-life care

Between 1994 and 1997, 360 patients enrolled in the CHF program; of the 120 who have died, 80 percent were at home, and 30 percent were enrolled in hospice.

The CHF Case Management Program coordinates its services with:

• Hospice and palliative care
• Home health
• Mental health and social services
• Inpatient discharge planners
• All in- and outpatient services
• Primary care providers

Such integrated services require that each team member share information, an objective that requires teams to develop specific ways to routinely communicate about a patient's treatment and status.

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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved. For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ].