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home, interdisciplinary, outpatient, palliative



  1. Gibson, Susan RN, FNP-BC, ACHPN
  2. Bordofsky, Michael MD
  3. Hirsch, Julie RN, CHPN, PHN
  4. Kearney, Michael MD
  5. Solis, Mary LCSW
  6. Wong, Colleen LCSW


Palliative care, although relatively new in the United States, has grown tremendously over the past 10 years. Historically, in this country, it has been predominantly delivered in an acute care setting. Many different models of delivery within that setting have evolved: consultation, primary care, and unit based. It has been successful with many studies substantiating this. But patients spend the majority of their time at home. Outpatient palliative care programs are growing, and recent studies indicate good outcomes. Literature demonstrates that, as with the inpatient services, these community programs come in many staffing matrixes with different models of delivery and under many different monikers. This article explores the innovative approach that one community devised to provide palliative care services to patients and their families outside an acute facility. Referrals, staffing, care setting, and care processes that were developed when the patient and family are placed at the center of the care plan are discussed. The article describes this non-hospital-funded, interdisciplinary, predominantly home care model of delivery of palliative care services.