title: Demonstration of a sustainable community-based model of care across the palliative care continuum.
abstract: BACKGROUND
  In the U.S., the number of hospital-based palliative care programs has increased rapidly, but availability of outpatient palliative care remains limited. Multiple barriers impede the financial viability of these programs. Four Seasons, a nonprofit organization in western North Carolina, delivers a full spectrum of palliative care in hospitals, nursing homes, assisted living facilities, patients' homes, and outpatient clinics; its catchment area encompasses approximately 350,000 people. Initially focused on hospice care, Four Seasons added its palliative care program in 2003. Before the inquiry described herein, financial losses from outpatient palliative care (2003-2008) were escalating.
  
  
  OBJECTIVE
  We explored organizational and financial barriers to sustainability of palliative care, so as to 1) identify reasons for financial losses; 2) devise and implement solutions; and 3) develop a sustainable model for palliative care delivery across settings, including the outpatient setting.
  
  
  METHODS
  In 2008, Four Seasons's palliative care program served 305 patients per day (average) with 10.5 providers (physicians, nurse practitioners, and physician assistants); financial losses approached $400,000 per year. We used Quality Assessment and Performance Improvement cycles to identify challenges to and inefficiencies in service provision, developed targeted strategies for overcoming identified barriers to cost-efficiency, instituted these measures, and tracked results.
  
  
  RESULTS
  In 2011, Four Seasons served 620 palliative care patients per day (average) with 14 providers; financial losses decreased by 40%.
  
  
  CONCLUSIONS
  With health care reform promoting integration of care across settings, outpatient palliative care will gain importance in the health care continuum. Process changes can help reduce financial losses that currently impede outpatient palliative care programs.
authors: Four Seasons, Flat Rock, North Carolina 28731, USA. jbull@fourseasonscfl.org
authors: Janet H
authors: JH
authors: Bull
authors: Elizabeth
authors: E
authors: Whitten
authors: John
authors: J
authors: Morris
authors: Richelle Nugent
authors: RN
authors: Hooper
authors: Jane L
authors: JL
authors: Wheeler
authors: Arif
authors: A
authors: Kamal
authors: Amy P
authors: AP
authors: Abernethy
mesh_terms: D003153:Community Health Services / Q000458:organization & administration*; D017046:Cost Savings / Q000379:methods* / Q000706:statistics & numerical data*; D017048:Health Care Costs / Q000706:statistics & numerical data*; D018803:Models, Economic; D017146:Models, Organizational; D009657:North Carolina / Q000453:epidemiology; D015279:Organizational Culture; D009937:Organizational Objectives / Q000191:economics; D010166:Palliative Care / Q000458:organization & administration*