Community-Based Palliative Care


Community-Based Palliative Care

California leading the way

By Sue Montgomery, RN, BSN, CHPN
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Although I had been a hospice nurse for many years, my first encounter with the magic of community-based palliative care didn’t take place until my own mom was in need.

Faced with her decreasing mobility, we finally came to a point at which it became impossible for her to make the required monthly trip to her pain specialist’s office. Hospice care wasn’t an option at that point, for several reasons, and I was becoming concerned about how we were going to continue getting the pain medication she needed.

I mentioned my dilemma to a friend and former hospice colleague, who told me about a new community-based palliative care practice that had just opened in our area. Manned by three former hospice medical directors, the program allowed enrolled patients to receive in-home physician visits for pain and symptom management needs. It was exactly the answer we needed. Mom received wonderful care from one of their physicians even as she transitioned into hospice in the final weeks of her life.

Since that experience, I’ve been on a mission to emphasize how community-based palliative care is a much-needed, growing model for empowering patients. I’m not alone — California is one state that is leading the way in promoting this type of care.

What Is the Difference Between Palliative Care and Hospice?

Many assume that palliative care and hospice care are the same thing, but they’re not. Palliative care provides an interdisciplinary, patient-centered approach to pain and symptom management that still gives patients the flexibility to pursue the treatment options they desire. This more comprehensive care model bridges the gap for patients who either aren’t ready or aren’t eligible for hospice care.   

Hospice care holistically supports individuals who are facing terminal illness, focuses on comfort, and always includes palliative care. However, stand-alone palliative care can benefit anyone with severe illness. Although palliative care has been available in hospitals for many years, access for individuals in their homes and other settings has been more limited. Fortunately, community-based palliative care programs are growing across the country.

California’s Legislation

California has been at the forefront of that trend. S.B. 1004, enacted in 2014, requires the state’s Department of Health Care Services (DHCS) to “establish standards and provide technical assistance for Medi-Cal managed care plans to ensure delivery of palliative care services.”S.B. 1004 is being implemented through pilot programs focusing on a limited range of eligible conditions.

DHCS is also integrating feedback from key stakeholders, which have included the Coalition for Compassionate Care of California; the California Health Care Foundation (CHCF); the University of California, San Francisco; and representatives from health organizations around the state. The latest stakeholder update, which DHCS published on September 8, notes that offering palliative care to Medi-Cal beneficiaries “can reduce patient suffering and unwanted hospitalizations and ED visits.” (The full report can be found on the DHCS website,

Reaching Out to Community Clinics

In addition to the impact of S.B. 1004, there’s the California State University Institute for Palliative Care, founded in 2012, which CHCF touts as “America’s first statewide educational and workforce development initiative, which is also impacting palliative care education nationally.” The Institute offers an array of multidisciplinary trainings and events for healthcare professionals working in palliative care. (Visit

At the CHCF’s Palliative Care Innovation Forum last May, Helen McNeal, the institute’s executive director, emphasized the importance of palliative care education in primary care settings. “It’s so important to reach out to the community clinics, to the primary care providers, because that’s where most Americans get their healthcare,” she said. The goal, she explained, is “ensuring that every person who has a series of chronic illnesses has access to palliative care when they need it, from point of diagnosis onwards.”The forum included a number of palliative care leaders from across the state, who spoke about trends in palliative care in California. (You can view four excellent videos from that event at the CHCF website,

Palliative Care Pioneer

One of those leaders is Michael Fratkin, M.D., president and founder of ResolutionCare, a community-based palliative care provider and educator in Northern California. Fratkin is a pioneer, both in California and across the nation, in making the most of technology to shift the center of care and support to patients in their own homes, no matter where they may be. Fratkin says that although the healthcare industry has recently had increased calls for person-centered care, the palliative care community has long embraced that model. “It’s the way we approach caring holistically for the complete person,” he says.

“There is a movement away from hospitals to clinics to home-based care, both here in California and across the country. Community-based palliative care has traditionally included clinic settings, but the more revolutionary approach is home-based care.” He says S.B. 1004 is making California an “extraordinary laboratory for palliative care.” However, while the law seeks to provide community-based palliative care benefits for the millions of Californians who are Medi-Cal beneficiaries, he says there’s a lack of infrastructure with which to do it.

A 2015 CHCF report, compiled shortly after the enactment of S.B. 1004, warned that statewide, there were only enough community-based programs to meet about 29 percent of California’s palliative care needs.Fratkin says the ResolutionCare model helps to meet that need. “We build out network capacity through the use of technology,” he explains. “Our hybrid model means that we can have boots on the ground by engaging in strategic partnerships while reaching patients to provide care through telehealth technologies — no matter where they may be, even in remote areas.

”Expanding rural capacity is important because many rural counties have no community-based programs at all. Some don’t even have inpatient ones. “There are 35 critical-access hospitals in California, but none of them have palliative care programs,” says Fratkin. “We can help to meet the need for palliative care in these types of settings through remote technology.”

The Role of Nurses

When I told him I was writing an article for a nursing audience, Fratkin was eager to be included. “In my opinion, nurses are some of the most undervalued healthcare professionals when it comes to the potential to transform the healthcare model,” he says. In addition to creating better quality of life for patients, Fratkin says he also wants to make that possible for providers. “At ResolutionCare, we’re creating a new way of working for healthcare professionals,” he explains.

“We hope to increasingly allow people to be part of something bigger, using technology to work in a manner that works for them, woven together in a virtual team environment from all over the state. In this way, we could help healthcare professionals that have been squeezed into the system to own their own lives again.” Fratkin says that the healthcare workforce of the future is going to be part of a sharing economy — a gift economy — rather than marching through the industrialized work structures it endures today.

His vision for the future allows care to go both ways. “In this type of outside-the-box delivery model,” he notes, “we can serve both the people we care for and the people who provide the care.” 


S.B. 1004 Care Model for Medi-Cal Beneficiaries

• Early palliative care: Typically consists of advance care planning and/or palliative care consultation, often including pain and symptom management, usually in combination with disease-modifying/curative care.

• S.B. 1004 palliative care: Palliative care programs for patients with serious illness who meet specific clinical criteria.

• Hospice care: Programs for patients who meet hospice eligibility criteria (six-month prognosis). A patient can enroll in either hospice or S.B. 1004 palliative care, but cannot enroll in both programs at the same time.

Source: DHCS S.B. 1004 Medi-Cal Palliative Care Policy Update, Sep. 8, 2016


Palliative Care Resources

•  California Department of Health Care Services (DHCS)

• California State University Institute for Palliative Care

• California Health Care Foundation (CHCF)

• Coalition for Compassionate Care of California (CCCC)

• ResolutionCare

• Center to Advance Palliative Care (CAPC)

• National Hospice and Palliative Care Organization (NHPCO)


Sue Montgomery, RN, BSN, CHPN, been a nurse for 32 years in various settings and roles, from staff nurse to administrator in critical care, hospice and the health insurance industry. She is a freelance healthcare writer, editor and communications consultant, specializing in supporting the writing needs of executives in healthcare and related industries. Her website is

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