“Good palliative care means continuity of care. Our job is not truly finished until we have taken a step beyond the hospital’s four walls.” – Mary Ersek

Transferring patients from hospital palliative care to nursing home palliative care requires careful planning and coordination between numerous parties, including family members and medical teams. Nearly two-thirds of nursing home residents have multiple, chronic conditions, such as dementia or alzheimers. These individuals are the most likely to benefit from palliative care.

In these “Notes from the Field,” published in the Journal of Palliative Medicine, academic and medical professionals discuss the transition from hospitals to nursing homes. William Smucker, M.D., a family practice physician at a teaching hospital in Ohio, relates the circumstances of a meeting between hospital staff and representatives of a local hospice—following the meeting, several hospital patients received palliative care consultations; Mary Ersek, a professor of nursing at the University of Pennsylvania, preaches “close communication,” between palliative care teams at hospitals and nursing homes.

The authors review a 2007 report from the Center to Advance Palliative Care (CAPC); present four models for palliative care; and, provide tips for strengthening the interaction between hospital palliative care practitioners and nursing home personnel.

Key Findings:

• Federal and state regulations often conflict with the provision of palliative care.
• The four emerging models for palliative care are: non-hospice palliative care consultation; nursing home palliative care; managed care; and, hospice-based palliative care.
• Involving family members in care planning can help communication between facilities.

This article considers the challenges of moving patients receiving palliative care in hospitals to long-term palliative care.