Palliative Care Continuum

The 2015 Institute of Medicine Report: Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life noted that while hospice care has now become mainstream, there are still gaps in care at the end of life.  Many individuals are not engaged in thinking about and expressing their preferences for end of life care. Systems established for curative care are not well integrated with palliative and hospice care.  The IOM concluded that improving the care continuum could improve quality of life for patients, reduce the use of unwanted services, and improve the experience of patients and families.
In Spring, 2016 VNAA convened a work group of members representing home health, hospice and palliative care to examine what home-based care organizations can do improve the continuum of care at the end of life. The group identified innovative approaches for home-based care organizations to interface with patients, communities, and other health care providers to improve the continuum of care. This module focuses on reducing barriers and developing the environment for an improved  Palliative Care Continuum.  For patient-specific clinical interventions, see other sections of the Hospice Module.
Case Example: Concord Regional VNA's New Palliative Care Collaboration

VNAA Best Practice Recommendations

Best Practice: Engage the Community
  • Identify grant funding for the hospice to produce advance care planning sessions or seminars
  • Identify sites for community outreach presentations on advance care planning, including senior centers, Knights of Columbus, assisted living
  • Use tools already developed such as the Conversation Project or POLST programs
  • Provide advance care planning information in multiple languages
  • Conduct community outreach by making  information available to the patient in the community. Promote tools such as the Conversation Project,  National Hospice and Palliative Care Organization’s CaringInfo material for patients and caregivers
  • Use terminology that works in your community: sometimes ‘advance care planning’ is tolerated better than ‘end of life discussions.’
Best Practice: Partner with Local Physicians on Increasing Advance Care Planning
  • Develop information for physicians on how to bill for Advance Care Planning services
  • Reach out to geriatricians and internists re hosting an evening session on advanced care planning
  • Develop a program in collaboration with local physicians in which the hospice can present on advanced care planning and the physician can offer a billable personalized session
  • Develop trusted relationships with referral source physicians (those serving elder populations in particular), including oncologists, cardiologists, internal medicine with older populations (get the providers behind you first. Ultimately the goal is to build a network of practitioners supportive of palliative and hospice care.
Best Practice: Partner with Hospitals to Develop Continuum of Care Programs
  • Identify key sources and contacts within the hospital who may support initiatives to improve the continuum of care.  This may include hospital case managers, discharge planners, and hospital based palliative care teams.
  • Use data to engage hospitals and ACOs on the importance of end of life planning, including evaluation of data on deaths in the hospital and use of the ED at end of life
  • Identify a model for a continuum of care that includes inpatient and home-based palliative and hospice programs and work with the hospital to implement the model
  • Have a hospice team member join a care transition team at the hospital
  • Start a ‘Conversation Project’ committee at the hospital or ACO.  Use resources such as the “Respecting Choices Model” to promote cross-system consistency on EOL planning.
Best Practice: Understand and Address the Motivations of Other Stakeholders
  • Research key regulatory drivers and performance measures of other partners such as hospitals and nursing facilities. For example, penalties for readmissions has created more interest in both of these entities in partnering with home-based care organizations.
  • Offer solutions to partners that help them meet requirements – for example, offer them assistance with patient-centered planning and advance care plans.
  • Become an expert advisor to Medicare Advantage Plans seeking to develop a continuum of care.
  • Build community capacity for a better end of life continuum.  For example, offer the agency as a site for practicums or mentoring for health professional students, including medical, nursing, physician assistant and certified nursing assistant (CNA) students. This may be a long-term strategy for some professions, but can also help with recruitment of CNA’s
Best Practice: Build Continuum of Care in the Agency Including Palliative Services
  • Evaluate the opportunity to provide palliative care services through the home health side of a blended hospice and home health organization
  • Identify patient need and potential for improved quality of life
  • Identify payment options, including Medicare, Medicaid, private pay, and grant funding
  • Document the ‘business case’ for each payer, using return on investment tools.  Note ‘value’ of palliative services may differ for different stakeholders, and include:
    • Improved quality, particularly relating to pain, dyspnea, function, and medication related measures
    • Improved patient experience
    • Cost savings for payers through reduced hospitalizations; reduced ER visits; reduced ICU days
  • Increased hospice referrals and/or increased hospice length of stay.
  • Use data and information on cost, return, and performance to secure buy in from payers, the agency board, and key sta


End of Life Policy  Palliative Care Information Caregiver Support 

Hospice and Palliative Care Quality Measurement and Reporting

Page Reviewed November 2019