Palliative care fills a vital gap in the health care system, providing symptom control and social support to keep very sick people from cycling in and out of the hospital. But palliative care typically is not reimbursed directly. Now, a highly integrated health system in San Diego, Sharp HealthCare, has found a potential remedy for that dilemma by using palliative care as an essential part of a coordinated care payment model. Its innovation, and its implications for a brighter future for palliative care, earned Sharp one of three 2012 Circle of Life Awards.

Akron Children's Hospital's palliative care program also received a Circle of Life Award, which recognizes innovation in palliative and end-of-life care. In just 10 years, Akron has built a comprehensive program that serves children in a wide swath of Ohio, including a strong practitioner training and research component. The third winner is Calvary Hospital in New York City, which has been providing mostly cancer patients with compassionate end-of-life care for 113 years, with more recent innovations in wound care. Ther hospital also trains most of New York's medical students in palliative care.

Receiving citations of honor in the program this year were Community Hospice of Northeast Florida; St. Joseph Hospital in Orange, Calif.; and Unity Limited Partnership in De Pere, Wis.

The 2012 awards are supported in part by the California HealthCare Foundation, based in Oakland, and the Archstone Foundation in Long Beach, Calif. Major sponsors of the 2012 awards are the American Hospital Association, the Catholic Health Association and the National Hospice and Palliative Care Organization & National Hospice Foundation. The awards are cosponsored by the American Academy of Hospice and Palliative Medicine and the National Association of Social Workers, with additional support from the Hospice and Palliative Nurses Association.

WINNER | Sharp HealthCare

Sharp HealthCare, a large integrated health system in San Diego, covers the care continuum — following patients from one setting to the next. That makes it easier to provide palliative care whenever needed, rather than trying to fit it into one reimbursable episode of care. And Sharp's participation in new models of coordinated care means palliative services, for the first time, actually fit well with the financial side.

"We can do this transition because we're compensated for people's care, so we're figuring out how best to manage their health over the long term," explains Nancy Pratt, senior vice president of clinical effectiveness for Sharp. "It gives us an opportunity to innovate and create." Sharp has been providing its Medicare managed care patients with new palliative care options and will be able to expand as a participant in Medicare's Pioneer Accountable Care Organization program.

The care models are as innovative as the reimbursement models. Sharp devised a program called Transitions that takes a population-based approach to identify people at the very beginning of an illness that could lead to a need for palliative services. Transitions focuses on specific diagnoses. First up was congestive heart failure. The program manages patients closely to keep them from having to go in and out of the hospital.

"The model is evidence-based. … We know the typical course of heart failure patients, and if we look two years upstream, we help anticipate what they need to do to successfully manage their disease," explains Suzi Johnson, R.N., a Sharp vice president. "We know that falls, medication issues and caregiver problems are the drivers of hospitalization."

The Transitions model is built on four pillars of care: in-home skilled care, evidence-based prognostication, care for the caregiver, and goals of care discussion. "We give physicians another tool so they don't have to use the word ‘hospice' with their patients" who aren't ready for it, says Johnson. "We help patients avoid a crisis by putting them in this program. We're really helping to create a roadmap for patients and families." Patients can continue on curative care while in Transitions.

The prognostication piece has taken particular work to help doctors be more open about the likely course of a patient's illness, says Daniel Hoefer, M.D., the program's medical director. "We stopped teaching prognostication 30 years ago. We used to think it was just as important as diagnosis and treatment, to tell the family about the natural course of disease."

The results so far are "stunning," program leaders say — huge reductions in the number of emergency department visits and hospitalizations, and substantial improvements in quality of life, patient satisfaction and earlier hospice referral. Among heart failure patients there was a 94 percent reduction in ED visits. Transitions has since moved on to COPD, dementia and end-stage cancer.

In addition, a pilot program using remote monitoring to reduce readmissions for heart failure is focused on unfunded, Medi-Cal and Medicare fee-for-service patients.

For organizations that follow Sharp into the world of ACOs, palliative care will be an essential part of managing the care of patients with serious chronic and life-threatening illnesses, says John Jenrette, M.D., CEO of Sharp Community Medical Group and a leader of the Pioneer ACO initiative. "There's a huge opportunity both in quality and cost savings," he says. "The palliative piece is just an obvious fit. And just as important, there are the improvements in care for patients and families."

WINNER | Akron (Ohio) Children's Hospital

Lauren Gartner, like many 10-year-olds, loved to draw, and it was the most fun when she could make pictures with her best friend Maddy. Unlike other kids, however, Lauren had a tumor that would shorten her life. "Her hospital room was lit up with her art work," recalls William Considine, CEO of Akron Children's Hospital, where she spent much of her six-month illness. "She had such a positive energy and spirit that inspired all of us."

That spirit also inspired the palliative care program to build on Lauren's love of creativity to design a special place where children and families can experience holistic healing through the arts. The result, eight years later, is a new, colorful, sunny 3,000-square-foot space called the Expressive Therapy Center, built with the support of a major donor, Emily Cooper Welty. Children and families can use its resources there or in a patient's room. "Sometimes they'll just take something out and play while they're talking," explains Marlene Hardy-Gomez, a nurse practitioner on the hospital's palliative care team.

The center is just one part of Akron Children's comprehensive palliative care program, which was created and developed by Sarah Friebert, M.D., a pediatric hematologist/oncologist and palliative medicine physician. Friebert evangelized the cause of palliative care so effectively that after just 10 years, the hospital now has one of the nation's leading pediatric palliative care programs.

"We built a community-based model that recognizes [that] children in the hospital need palliative care," Friebert says. "But what we also need to be doing is reducing the fragmentation" of medical care, she adds, "and getting them back to where they want to be — in the community."

The program offers in-hospital consults, but much of the care takes place in other settings with home care and hospice agencies, schools and long-term care facilities scattered around 44 of Ohio's 88 counties. "We drive a lot," says Friebert.

Her enthusiasm for palliative care was infectious and fit well with the mission of the 122-year-old children's hospital. "The idea of palliative care is very strongly tied to the hospital's family-centered care focus and mission," Considine says.

The palliative program has grown from three staff members to 29. Akron Children's became one of the first hospitals to maintain a pediatric palliative care fellowship and the first to endow a chair in pediatric palliative care. The chair, which bears Friebert's name, and the center itself receive extensive financial backing from the Haslinger family, whose generosity has inspired other donors to support the program and the hospital.

The program has changed the medical culture of the hospital, says Pediatrics Chair Norm Christopher, M.D. "It's required us to think a little bit differently about children with complex medical conditions and chronic conditions. It called into question how we address these very complicated situations that families find themselves in."

Palliative care now has become an intrinsic part of medical care at Akron Children's, Christopher says, even if it doesn't fit neatly into an organizational box. "A few years ago we reorganized the department of pediatrics into practice clusters and everything fit pretty nicely, but not palliative medicine. So we thought about it as a golden thread that pulls all those other service lines together."

WINNER | Calvary Hospital

Calvary Hospital has a unique and dramatic place in the history of the care for the dying in New York City. It was established in 1899 by a woman who observed the "calvary homes" of Europe that cared for poor, mortally ill widows abandoned by society to literally die in the streets. Long before palliative care became part of mainstream medical care, the concept was in practice at Calvary's first location in Greenwich Village and later at its facility in the Bronx.

Today, Calvary Hospital is a far bigger, more sophisticated, complex organization. It sees fully one-third of those who die from cancer in New York City. It offers palliative and end-of-life care both at its main 200-bed hospital in the Bronx and at a 25-bed unit at Lutheran Medical Center in Brooklyn.

The hospital provides a comprehensive, integrated palliative care program across the continuum, including home care, ambulatory services, home hospice and nursing home hospice. And it has been a model for end-of-life care delivery around the world, welcoming many foreign visitors from areas where palliative care is very new, such as Turkey, Japan and the Middle East.

Calvary also plays an enormous role in training new practitioners. Nearly all the medical students in the city cycle through Calvary at some point during their education. It also has a special training program for cancer care technicians who take on the difficult and time-consuming tasks of the everyday care of cancer patients. They attend a rigorous six-month course to learn to feed, wash and do basic wound care, and what Michael Brescia, M.D., executive medical director, calls "glorifying the body," even if that body is sickly and failing. The technicians become an important part of the care team, and many have stayed on, undertaken nursing education, and become registered nurses. One former technician ended her career as a vice president and director of nursing.

Calvary's leadership and caregiving staff are passionate about its mission and work. Brescia left a promising career in nephrology and transplant surgery in the mid-1960s to help dying patients at Calvary. He and his nephrologist colleague James Cimino, M.D., were involved with the invention of the arteriovenous fistula — the procedure that made kidney dialysis practical — when they both became caught up in the compelling mission of Calvary. Cimino died in 2010 after many years as director of Calvary's Palliative Care Institute.

Another Calvary innovation, the Family Intervention Team, is particularly helpful for patients' loved ones who have not fully accepted the seriousness of the illness, explains Robert Brescia, M.D., a cousin of Michael Brescia and director of psychiatry for Calvary.

The team includes caregivers and senior Calvary administrators, who sit down with a struggling family member to discuss the situation. Their open approach often starts with, "Tell us what we're doing wrong."

"We have a high success rate in really calming family difficulties down, really easing their pain and suffering," Robert Brescia says.

Despite the growth and evolution of its programs to accommodate modern medicine, the core values of Calvary Hospital haven't changed since the 19th century. Boiled down to a phrase, it's "no one is abandoned."

Citations of Honor

Community Hospice of Northeast Florida, Jacksonville

The hospice's pediatric care program, PedsCare, provides comprehensive palliative and end-of-life care to children and families across all venues, maintaining a family-centric and community focus.

St. Joseph Hospital, Orange, Calif.

The hospital has a primary palliative care approach combined with specialty service, with multiple triggers for palliative care involvement.

Unity Limited Partnership, De Pere, Wis.

The hospice serves many rural and isolated communities with a highly integrated approach, using the same team for both palliative and hospice care.

About the Award

The Circle of Life Award honors programs that are striving to provide effective, patient-centered, timely, safe, efficient and equitable palliative and end-of-life care; show innovation in approaches to critical needs and serve as sustainable, replicable models for the field; and are actively working with other health care organizations, educational and training programs, and the community. For the complete criteria and other information, visit www.aha.org/circleoflife.