BOX S.1 A Whole-Community Model for Care at the End of Life

Programs and settings of care suited to the needs and circumstances of different kinds of dying patients

Home hospice programs

Other palliative care arrangements for patients that do not fit the home care model

Day programs in hospitals and nursing homes, similar to those developed by geriatricians

"Step-down" arrangements including nursing homes that permit a less intensive and less expensive level of inpatient care when appropriate

Specialized inpatient palliative care beds for those with severe symptoms that cannot be well managed elsewhere

Respite programs to relieve families of patients with a long dying trajectory (e.g., those with Alzheimers Disease) that imposes major physical and emotional burdens on families

Personnel, protocols, and other mechanisms that support high quality, efficient, timely, and coordinated care

Practical and valid assessment instruments and practice guidelines for patient evaluation and management that can be applied at both the individual and organizational level

Protocols for evaluating patient's need for referral or transfer to other individual or organizational caregivers

Procedures for implementing patient transitions in ways that encourage continuity of care, respect patient and family preferences and comfort, and assure the transfer of necessary patient information

Consulting and crisis teams that extend and intensify efforts to allow patients to remain home despite difficult medical problems or crises

Ongoing professional education programs fitted to the varying needs of all clinicians who care for drying patients

Performance monitoring and improvement programs intended to identify and correct problems and to improve the average quality of care

Public and private policies, practices, and attitudes that help organizations and individuals

Provider payment, coverage, and oversight policies that, at a minimum, do not restrict access to appropriate, timely palliative care and, as a goal, promote it

Support systems provided through workplaces, religious congregations, and other institutions to ease the emotional, financial, and practical burdens experienced by dying patients and their families

Public education programs that aim to improve general awareness, to encourage advance care planning, and to specific information at the time of need about resources for physical, emotional, spiritual, and practical caring at the end of life

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