Palliative Care


This initiative seeks to provide enhanced quality and access to care at the end of life through the integration of palliative care with traditional care management services.  The initiative goals are:


  1. Improve information dissemination and access to hospice and palliative care services

  3. Enhance patient autonomy through increased use of advance care planning communication in primary care practices

  5. Develop and disseminate clinical tools for pain and symptom management, psychological, spiritual and practical needs appropriate for primary care practices serving seriously ill patients


Specific activities have included:


  • Development and delivery of a curriculum and toolkit for care managers to enhance clinical skills, including:
    • advance care planning communication
    • assessment of major sources of patient distress in serious illness
    • screening procedures that help identify patients who are potentially appropriate for hospice


  • Enhancing systems to incorporate primary care documentation tools for key components of advance care planning, such as living wills, Health Care Powers of Attorney, portable DNR orders and portable MOST forms

  • Partnering with local hospital Chaplaincy departments

  • Coordinated and facilitated advanced care planning workshops at long term care facilities


    Advance Care Planning

    Advance care planning is making decisions about the care you would want to receive, if you happen to become unable to speak for yourself. Those are your decisions to make, regardless of what you choose for your care and the decisions are based on your personal values, preferences and discussions with your loved ones.
    As a network, we ask three simple questions regarding advance care planning to help people start the process:


    • If you were unable to speak for yourself, do you have someone who can make medical decisions for you?
    • Thinking about the future, do you have this decision in writing that states the individual who you have identified to make medical decisions on your behalf if you are unable to speak for yourself?
    • Would you be OK if I have someone call you to go over how you can put this decision in writing?



    Advance care planning keeps the patient involved in medical decisions, both now and in the future, whether they are healthy or have an illness. Advance care planning is especially important when a patient becomes so unwell that they can no longer speak for themselves because doctors and family can understand the patients’ wishes for their healthcare. Research shows that patients who participate in advance care planning are more likely to utilize palliative and hospice care, have an increase in quality of life, and lower healthcare costs.



    To Make a Referral

  • Go to
  • Fax referrals to 919-510-9162