PCA For Hospitals

Palliative Care Alliance (PCA) is a healthcare solution that specializes in identifying patient risk level for readmissions, supporting discharge management processes, and providing patient management through transitional care.

Using experienced, clinical personnel, we have demonstrated significant patient satisfaction by providing:

• Care management processes at discharge
• Continuity of care at home
• Guidance and instruction regarding prescribed medication
• Education of signs and symptoms that often lead to readmission
• Increased patient and family satisfaction with the healthcare system
• Superior cost effectiveness for hospitals and health plans
• Ease of access to advance directive discussions
• Increased community resource provision and utilization

Services provided to patients at home include a physician, nurse and medical social worker. Together the team develops a plan of care to address the symptoms related to the patient’s acute or chronic illness. The patient will be seen in the home setting with as many visits that are considered appropriate based on the customized plan of care. Additional resources and specialty services can be offered in order to keep a patient in their residence, thereby avoiding re-hospitalization.

The primary objective in providing transitional services to seriously or chronically ill patients is to reduce unwarranted hospital readmissions while providing and maintaining quality healthcare. To accomplish this, identified ‘High-Risk’ Patients will be evaluated and managed by the PCA interdisciplinary team to:

• Assess the patient’s risk for readmission
• Develop individualized plan of care
• Make routine visits as determined by the team
• Provide outcome reports to hospital and community partners

The PCA transitional care service integrates patient discharge and post discharge care through consistent and timely visitation by an expert clinical team in the residential setting. This is achieved while maintaining exceptional patient care and leveraging the existing strengths of the hospital and their staff. The steps toward PCA implementation during hospital stay and post hospital admission include:

• Hospital referral of patient to Palliative Care Alliance (PCA)
• PCA is sent patient info prior to discharge and the Readmission Risk Assessment is completed
• PCA staff nurse helps hospital CM personnel coordinate the discharge plan for high risk patients
• At point of discharge, patient is educated by Hospital staff and PCA on what is to be expected post discharge
• PCA assumes management of patient care and tracks all events post discharge
• After 30 days, PCA completes patient care assessment noting significant events, applicable data, etc., and makes report available to hospital personnel
• Hospital and PCA meet quarterly to review progress, performance, and discuss potential program improvements