Policy experts trying to build a better health delivery system through coordination of care should talk to the innovators in end-of-life care. For years, they've been working to ensure their patients get the care they need whether in an intensive care unit, a hospice, at home or elsewhere.

This year's recipients of the Circle of Life Award exemplify the best in care coordination. They also recognize their role in a more patient-centered health care system, and are planning ahead to plug into whatever new organizations result from health reform. Among their tactics: embedding nurse practitioners in outside medical practices, providing seamless care to frail elderly patients in a variety of settings and partnering with faith communities to offer a consistent message about end-of-life care.

The AHA Circle of Life Award honors innovative programs in palliative and end-of-life care. The 2011 awards are supported, in part, by the Archstone Foundation and the California HealthCare Foundation, Oakland, Calif. Major sponsors are the American Hospital Association, the Catholic Health Association, National Consensus Project for Quality Palliative Care, the National Hospice and Palliative Care Organization and the National Hospice Foundation. The American Academy of Hospice and Palliative Medicine and the National Association of Social Workers are Circle of Life co-sponsors.

Center for Hospice & Palliative Care | Cheektowaga, N.Y.

The Center for Hospice & Palliative Care has been caring for the people of the Buffalo, N.Y., area for more than 30 years. But the organization keeps fresh and innovative by constantly strategizing for the future. For instance, its leaders recognized that entering hospice can present a psychological barrier for patients and families fighting an illness. "So we will embed oncology-based, nurse practitioner palliative specialists in collaboration with oncology practices," explains CEO Flint Besecker. The nurse practitioners offer aggressive symptom management and open conversations about the long term. "This partnering strategy with physician-practice groups is unique. We're trying to keep patients out of the ER and hospitals."

The alignment with medical groups is also consistent with the current federal focus on coordinating care through accountable care organizations. "We believe hospice will be a big part of ACOs, and we are thinking today about how we align ourselves with health systems that are likely to be the key drivers in ACOs," Besecker says.

Collaboration has always been a strength of hospice and palliative care. "If we're going to be successful in our mission of taking palliative care to patients in our community, we can't own 100 percent of the care," he says. "So that means we have to be partnering with a lot of different aspects of the care community."

One of the organization's goals is to provide care to all who need it without being constrained by reimbursement rules. The hospice maintains an open-access policy, using complex case management review. In 2009, CHPC admitted 700 open-access patients. "We want the latitude to make adjustments when the need is overwhelming," says Medical Director Christopher Kerr, M.D.

The hospice's electronic medical record is used in all settings and is accessible to team members on laptop computers. Daily notes are left in the hospital chart as well as in the center's EMR. The hospice also has access to EMRs of all local hospitals. Patient care is further coordinated by CHPC's partnership with a local pharmacy, which provides all prescriptions and deliveries for hospice-covered medications. The pharmacy has access to the EMR, reducing the potential for error.

The hospice plans to expand its 22-bed inpatient unit by 10 beds. "We have more requests for either symptom management or end-of-life care than we can handle," says Kerr. The benefit of the inpatient unit is that it is an environment that can be controlled, which improves care for complex patients.

Given the center's strategic approach, it's prepared to be flexible to face the future. "We have some pretty innovative collaborations going on" that will lead to caring for many more people, Besecker says. "That's where we're headed and we're really repositioning the entire organization to successfully fill the gaps that exist and extend care to a larger audience."

Gilchrist Hospice Care | Hunt Valley, Md.

Patients with serious illnesses move through the health care system quickly and unpredictably, confounding efforts to keep track of them and their wishes. And yet, careful coordination is crucial to high-quality care and to supporting the patient and family through their challenging journey.

Because the geriatricians at Gilchrist Hospice Care in Hunt Valley, Md., monitor patients and oversee patient care in multiple settings, ranging from home to skilled nursing facilities to hospital to hospice, their patients benefit from the greatest possible coordination. They do it so well that the physician group, Gilchrist Greater Living, gets regular inquiries from other health care organizations looking to move toward more coordinated, patient-centered care.

W. Anthony Riley, M.D., medical director of Gilchrist Hospice Care, says it's been challenging for physicians to track patients so closely and across so many care settings, but the results are well worth the effort. "Each setting has not only different cultures, but different regulations, staffing models and business models," Riley says. "That's a challenge. But our clinicians have learned to communicate, coordinate and collaborate around the patient's goals of care as a large, integrated team."

Ultimately, everyone benefits, says Gilchrist Executive Director Cathy Hamel. Providers are happier in their jobs, improving clinician retention and satisfaction. And the needs of the frail elderly, who need compassionate, comprehensive and coordinated care, are not lost in the shuffle among care settings.

"The frail elderly are worthy of our highest attention and need our care wherever they are," Hamel says. "When the care is done well, there are many rewards and satisfactions."

Riley notes that "Gilchrist Greater Living physicians, nurse practitioners and social workers are all triple-skilled in internal, palliative and geriatric medicine and are adept at both managing transitions between care settings and conducting difficult family meetings about advance care planning. They are there for the patient no matter where they are in their medical journeys, both literally and figuratively." Gilchrist calls it a "medical home" model for palliative and hospice care.

Gilchrist geriatricians serve as medical directors at 22 local long-term care providers, including nursing homes and assisted-living facilities, as well as at two hospital care units that serve mostly elderly patients and at hospice. A Gilchrist Greater Living physician, board-certified in palliative care, directs the palliative medicine program at the hospital. This structure helps break down the traditional "silos" created by reimbursement, regulatory and professional development systems that have, in the past, created a more rigid and less coordinated health care system.

Gilchrist officials frequently are approached by residential facilities that want to take advantage of its integrated medical home program, which takes a long-term, comprehensive approach to following older patients wherever they are."The fact that we have been tackling those issues has been noticed," says Riley.

St. John Providence Adult Palliative Care | Detroit

Inpatient palliative care often is focused in those parts of the hospital with the sickest patients. But not at St. John Providence Health System in Detroit. There, every admitted patient now is screened for palliative care needs, using nine triggers tested by the system's palliative care team.

As a result, more patients who would benefit receive palliative care services, and they get them at an earlier point in their illnesses. The comprehensive screening process has the side benefit of placing palliative care in the mainstream of everyday medical practice at the system's six hospitals. "The health system associates have become comfortable with palliative care; it has become part of usual care for patients with need," says palliative care nurse practitioner Mary Hicks.

St. John Providence emphasizes staff education to spread the word about palliative care. Annually, the health system sponsors a train-the-trainer conference and educates 150 multidisciplinary associates on basic palliative care. Trainers return to their departments and share what they learned.

The training includes all types of hospital staff. "We found that some of the most engaged individuals were people we did not anticipate, including dietary and housekeeping staff," says Liz DiStefano, the system's coordinator of palliative care. "They are sometimes by themselves with people who are suffering, and they were empowered by this education to respond." Education even went beyond hospital walls with a television commercial explaining palliative care to the public.

In part because of the system's mission, spiritual care is elevated to the same level as physical care. Jeanne Lewandowski, M.D., director of palliative medicine at St. John Hospital and Medical Center, believes that helping patients' cope with spiritual issues goes a long way toward their coping better with symptoms. "No amount of morphine is going to make a spiritual crisis go away," she says, "but if patients believe their spiritual needs are being addressed, they often need less medication."

Because it serves patients well to receive a consistent message about end-of-life care, staff started a dialogue with local clergy about how to help parishioners being treated for a serious illness. "We found that the leaders in the different faith communities very much want to be part of the health care ministry and want to be part of their congregants' lives even as they experience a serious illness," says Lewandowski.

The team credits health system leadership for supporting the program, which was under growth and development just as Detroit's auto industry was suffering a painful contraction. "So while cuts were going on everywhere, there was investment in systemwide palliative care services," recalls Hicks. "This was a truly leadership-driven project."