1. Inpatient Palliative Care A hospital service at SOMC where patients can benefit from palliative care consultative services during their hospitalization Coming: April 2016 Palliative Care: House Calls A provider based (NP) home service where the provider makes “house calls” to patients who are chronically ill and have difficulty with transportation, etc. August 2013 Palliative Care: Home Health Specialty palliative care service delivered to home health enrolled patients who have advanced symptom needs. February 2010 Hospice Palliative care service delivered to patients with a terminal illness; < 6 month life expectancy. Outpatient & Inpatient Services 1985 PC Cancer Center Clinic Referral based clinic that focuses on pain and symptom management in cancer patient undergoing treatment. Services are provided at SOMC Cancer Center. June 2014 PC Nursing Home Model Provided to residents at a nursing facility. Focus of care is on symptom management, communication and coordination of care. Does not replace NH primary physician. Currently at Piketon Nursing Center April 2015

2. Consultative services provided at SOMC Main Campus. Team Includes: Hospitalist physician oversight and collaboration, palliative care experienced nurse practitioner, and medical social worker. Chaplains available by request. Consults for: pain management, symptom management, discharge planning, transitions, coordination of care, advance directive focus, discussions for advanced treatment and decision making The inpatient team will focus on discharge planning to ensure patient has necessary options for care at time of discharge. INPATIENT PALLIATIVE CARE Coordinating Care: Inpatient to Outpatient Hospice: Patient’s referred to hospice care from referral of the inpatient team will be admitted prior to discharge and hospice services will begin immediately post- discharge. PC House Calls: Patient’s referred to house calls program from referral of the inpatient team will be seen by a palliative care NP within 72 hours of discharge for assessment, medication reconciliation and advanced care need coordination. PC Home Health: Patient’s referred to the home health program from referral of the inpatient team will be seen by a home health nurse within 48 hours.

3. Services provided in the comforts of the patient's home by a Nurse Practitioner Patients DO NOT require ‘skilled need’ or ‘homebound status’ as defined by home health regulations. Visits are based on medical necessity: 1x/week, 1x/month, etc. Consults for: pain management, symptom management, observation, coordination of care, advance directive focus, discussions for advanced treatment and decision making These are ‘high risk’ patients. Therefore, they have access to a 24/7 on call RN & Provider On-Call Team. HOUSE CALLS PROGRAM The House Calls program can be in addition to the Home Health program or can be independent, based on pt. needs. The House Calls providers do not replace the patient’s PCP – our practitioner will update and collaborate with the physician to determine appropriate intervention and the optimal careplan for the patient. Services can be provided to the patient wherever they call home; at their residence or ALF. House Calls also currently has a collaborative agreement with Piketon Nursing Center (SNF).

4. Services provided in the comforts of the patient's home (SNF) by a Nurse Practitioner Visits are based on medical necessity: 1x/week, 1x/month, etc. Consults for: pain management, symptom management, observation, coordination of care, advance directive focus, discussions for advanced treatment and decision making These are ‘high risk’ patients. Therefore, they have access to a 24/7 on call RN & Provider On-Call Team. HOUSE CALLS: SNF PRACTICE The House Calls providers do not replace the patient’s PCP – our practitioner will update and collaborate with the physician to determine appropriate intervention and the optimal careplan for the patient. In the SNF, the PC NP teams up with the patient’s primary physician and nursing team to help with advance careplanning and hold discussions for advance directives and difficult decision making concerning the patient’s medical treatment options.

5. Consultative services provided at SOMC Cancer Center every Wednesday afternoon Team Includes: Palliative Care LPN and Palliative Care NP. Consults for: advanced pain & symptom management, coordination of care, advance directive focus, discussions for advanced treatment and decision making 2007 American College of Chest Physicians (ACCP) & American Society of Clinical Oncology (ASCO) recommendation that all patients with metastatic non-small cell lung cancer be offered palliative care along with standard cancer therapy CLINIC AT SOMC CANCER CENTER Impact of PC Clinic: Patients receive aggressive symptom management to help with treatment compliance and completion. Physicians/Oncologist – more time to devote on cancer treatment plan Oncology team – improve/better symptom management of patients Home Health/Hospice – Improve coordination of referrals and transitions in a timely manner Cancer Committee – meet current accreditation requirements (ACOS Standard 2.4)

6. The patient’s PCP is our main collaborator and will assist in providing an effective plan of care for the patient and family Services can be provided to the patient in their home or at an Assisted Living Facility. The home health program can not go into a SNF.. Services Include: Skilled Nursing (Case Management & Crisis Management), Home Health Aid Services, Social Work Services, & Therapy Services Patients require ‘skilled need’ and ‘homebound status’ to receive services Visits are based on medical necessity: 1x/week, 2x/week and continue weekly until the skilled need is resolved Consults for: pain management, symptom management, observation, etc. Patient’s have access to 24/7 on call nursing services – nursing visits to home. HOME HEALTH PROGRAM

7. INPATIENT Imminent Death admissions are usually viewed as prognosis <72 hours. This is not exclusive. Respite Admission – Under hospice, patients receive 5 respite days each month to help alleviate caregiver strain. Patient’s can elect to utilize respite at any point of their illness, including at time of admission.. Caregiver Crisis – i.e. Family not ready for patient to return home, uncertain prognosis, etc. Pain/Symptom Mgmt. – Patient is still having difficulty in managing pain/symptoms, but is medically cleared to be D/C’d from hospital. OUTPATIENT & INPATIENT Very Specific Patient Population No Aggressive Treatment Terminal Illness Needed (<6 Months) Most Common Form of Palliative Care Currently OUTPATIENT Outpatient Hospice can follow a patient wherever they call home: residence, SNF, Assisted Living Facility, Group Home, etc. Services: Nursing (Case Management & Crisis Management), Social Services, Volunteer, Chaplain, Therapy, Dietary, and Short-term inpatient care. Bereavement services are also offered to families after the patient passes. Patients do not have to be DNR – if patient wish for Full Code, outpatient staff will address accordingly and ongoing.