Home Palliative, Hospice Services Provide Continuity of Care

Cleveland Clinic Center for Connected Care’s Palliative Medicine and Hospice at Home programs assist patients with life-ending illnesses in whatever setting they call home: a private home, assisted living, long term acute care facility or skilled nursing facility (SNF). “Seeing patients in the SNF setting can be especially helpful in transitioning patients from an acute hospital stay back to their home setting. This is an extra layer of care that most patients in a SNF don’t receive,” says Laura Shoemaker, DO, MS, the Center for Connected Care’s Director, Palliative Medicine and Hospice.

“Our palliative care program is a great option for patients with advanced illnesses including advanced COPD, congestive heart failure, dementia and cancer,” she says. “As disease advances and goals of care change, we facilitate a smooth transition to our Hospice at Home program.”

Engaged physician care

Engaged physician involvement is a key to the success of the Palliative Medicine and Hospice at Home programs. Connected Care’s hospice and palliative care providers make home visits for symptoms related to advanced illness or for ongoing discussions about care preferences and goals.

Connected Care’s palliative medicine providers include board certified hospice and palliative specialists, both physicians and nurse practitioners. These providers collaborate with the patient’s primary care physician and specialty providers and document and communicate using Cleveland Clinic’s shared electronic medical record. For patients enrolled with Cleveland Clinic Hospice, specialists are available to serve either primary or consulting roles.

Dr. Shoemaker adds: “Palliative care is like a bridge between the hospital and home settings. We use a holistic approach to support patients and their families while they are living with advanced illness. Involvement of palliative care assures that when a patient’s medical conditions and personal preferences align with a conservative comfort-focused plan of care, a timely hospice transition takes place.”

The Hospice at Home team includes hospice and palliative medicine physicians, nurses, social workers, chaplains, home health aides and volunteers.

Making the connection

The Center for Connected Care is actively working to increase access to hospice and palliative care in all of our hospitals and surrounding communities. Cleveland Clinic Hospice is contracted with all Cleveland Clinic hospitals to provide hospital-based care when needed.

Dr. Shoemaker says the importance of these programs cannot be understated: “This is often where we can have the most impact on our patients and their families.” To refer a patient to Hospice at Home or Palliative Medicine at Home, please call 855.REFER.123.