Providing the main hospice care for a large swath of Kentucky, in an area with some of the nation’s most challenging levels of chronic illness and poverty, means going beyond the traditional boundaries of late-life care. For Bluegrass Care Navigators (formerly Hospice of the Bluegrass), it’s meant finding new and innovative ways to reach people in many settings and stages of their lives.

The organization’s recent name change recognizes its expanded role. The agency includes hospice as well as transitional care, palliative care, grief care, a private duty nurse program and a new adult day health care program. The name Care Navigators was chosen to better reflect how the community sees the organization. “We are guides. We listen. We help people on a journey,” says Liz Fowler, president and CEO of Bluegrass, one of two winners of the 2017 Circle of Life Awards.

Bluegrass has a decadeslong reputation as an innovator that is constantly testing the limits of what a hospice can do. That role was bolstered not only by a population with significant health and social needs, but also by the state’s unique certificate of need status, which gave it a role as the area’s primary hospice — Bluegrass provides hospice care to more than 5,000 people in 32 counties. With that comes a profound sense of responsibility for meeting the needs of the population.

Chief Medical Officer Todd Cote, M.D., describes the organization’s approach as being open to any possibility, but also ensuring that new initiatives are worthwhile. “Our approach is science-based. We don’t just have a nice idea and jump into it,” he says. “We have well -thought-out ideas, we do our research, a needs assessment, strategize, and often do pilot projects to determine how best to serve our community.”

One example is its transitional care program, Bluegrass Transitional Care (formerly Kentucky Appalachian Transition Services). The program emerged from an insurer’s interest in long-term case management for some of its members and became part of a demonstration project funded by the Center for Medicare and Medicaid Innovation to reduce all-cause readmissions by 20 percent. After partnering with Appalachian Regional Healthcare System to tackle some high readmission rates, Bluegrass assigned home coaches to patients identified as needing extra attention in southeastern Kentucky and West Virginia. Results were impressive (a 37 percent decline in readmissions), and the transitions program has since been adopted by several departments at the University of Kentucky health system, including screening in the emergency department, which identified a homeless population needing the coaches’ help.

Bluegrass leaders see their organization as a problem solver that helps others while also fulfilling its mission of extending care to the communities, individuals and families. “We have to have a passion for the work and be expert at it,” Fowler says. “We want to help people live their lives fully.”

Circle of Life Award Citations of Honor

LifeCourse, Allina Health, Minneapolis: A unique program that assigns trained laypeople as advocates for patients on care teams for the seriously ill.

Midland Care, Topeka, Kan.: A longtime hospice provides services across the continuum to seriously ill patients in a large, rural section of northeast Kansas, innovating with a Program of All-Inclusive Care for the Elderly that helps elderly patients stay at home.

University of Wisconsin Palliative Care, Madison: Academic medical center palliative care program specializes in helping clinicians better communicate with patients and families with research-based techniques.

The Circle of Life Awards honor programs that strive to provide effective, patient- and family-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; demonstrate significant impact on people with life-limiting illness and those around them; and actively work with other health care organizations, educational and training programs, and the community. The Circle of Life Awards are supported by the California Health Care Foundation and Cambia Health Foundation and sponsored by the American Hospital Association, the Catholic Health Association, the National Hospice and Palliative Care Organization and the National Hospice Foundation. Co-sponsors are the American Academy of Hospice and Palliative Medicine, the Center to Advance Palliative Care, the Hospice and Palliative Nurses Association/Hospice and Palliative Credentialing Center/Hospice and Palliative Nurses Foundation, and the National Association of Social Workers. For complete criteria and other information, visit