RCHC Community Project Abstracts

Back to subject search page or search by preceptor site Advance Care Planning Project Date: 8/3/2009 Gold Beach has a large percentage of elderly population. The largest age group is 45-64 at 33.5%, above the 27.1% of the Oregon average. The group of 75-84 year-old is at 9.1%, double the Oregon average. Heart disease, cancer and chronic lower respiratory disease are listed as the top three causes of death in Gold Beach from 2001-2005. Advance care planning seems to be more pressing in a small town with a higher elderly population. POLST and Advance Directives are available to facilitate the discussion of advance care planning. After witnessing two patients pass away in the ER with a POLST and DNR during my first week, I want to explore how the hospital and the providers in a small town manage advance care planning. How is Curry General Hospital incorporating POLST and Advance Directives into the care of their patients? The project involves chart review of recently hospitalized patients in 2009 to obtain a baseline of the number of people with and without such forms. Interviews were then conducted with the nursing, medical, and administrative staff to understand how the hospital manages these difficult issues. Recommendations were made based on the chart reviews and discussion with the staff. Utilization of the POLST Form in Long Term Care Facilities in John Day, Oregon Project Date: 6/29/2009 The POLST (Physician Orders for Life-Sustaining Treatment) has helped translate patient wishes into tangible and specific Physician’s orders and helps to ensure that patient wishes during the dying process will be honored across various care settings. The use of the POLST form has increased dramatically since it was first developed at OHSU in 1991. Data from study done in 2004 showed that approximately 96% of Nursing Homes in Oregon used the POLST for around 50% of their residents. Furthermore, another study in Oregon indicated that rural areas are more reluctant to use the POLST forms and usage was less in these areas. My goal was to study the utilization of the POLST form in all of the long term care facilities in and around John Day, Oregon. I reviewed charts at Blue Mountain Nursing Home, Valley View Assisted Living, Country Spice Residential Care Facility and Blue Mountain Hospice. I also interviewed the directors of Elderberry House and Golden Heritage which are both adult foster care homes in John Day. I found that 100% of residents at these facilities have a POLST form in their charts and staff are well aware of the POLST and the patient’s wishes. Directors and staff at these facilities were also educated regarding the POLST Registry which is a way for emergency personnel to access the POLST when the actual form is not available. Further exploration needs to be done to assess the utilization of the POLST form among dying patients at home who are not living in a long term care facility and who are not involved in Hospice. End-of-Life Care Decision Making in the Illinois Valley Project Date: 3/16/2009 The importance of end-of-life care can not be understated, it is the last thing we do for our patients. It has been an area of research and systemic improvement for 15 years, but we continue to see limitations in our care, namely short median stays in hospice (17 days in Oregon) and rural/urban discrepancies in percentages of resident deaths that are hospice enrolled (46% in Multnomah County vs. 36% in Josephine County). This project attempts to delineate patients' values in when considering end-of-life (EOL) care in order to examine some the upstream variables that determine how and when we provide EOL care. The design was a qualitative assessment of community members' values in EOL care decision-making through individual semi-structured interviews and anonymous voluntary surveys of community members and primary care providers (PCP). It was found that among patients that have discussed EOL with their doctor, PCP was the most influential person in their decision on EOL, though specialist and family members were also important inputs. Assessment of Barriers To Hospice Referral In Baker City, Oregon Project Date: 2/9/2009 Hospice services have long been recognized as an important component in the spectrum of healthcare but certain barriers to referral still exist. This study attempted to assess potential barriers to referral in Baker City, Oregon by looking at perceptions, attitudes, and knowledge of hospice services by local primary care providers. Initial information was gathered through personal interviews with patients, hospice workers and physicians. The results of the interviews were that referral habits likely varied by age and experience of the physician, with older physicians being less likely to refer. Similarly, a lack of knowledge was thought to inhibit referral. An anonymous survey was then collected from 6 out of the 9 primary care physicians in town which assessed attitude, knowledge, perceived benefits and perceived barriers to referral. The results showed that every physician surveyed had a high level of knowledge about hospice services and requirements and that this did not likely affect referral rate. There was consistency between local opinion and what was found regarding age of physician with the one responding senior physician being less likely to refer. This was determined to be likely due to a poor interaction history between the physician and local hospice services. Additional responses from the other senior physicians in town could not be obtained, so no generalizations could not be made. However, it was evident that the greater factor that influences many aspects of small town life is determined by how well people work together. Access and quality of Hospice services for patients and physicians in Josephine County; continual strives towards quality assurance Project Date: 9/8/2008 Rural communities in Oregon are facing the aging population of baby boomers. As such the demand for physicians and Hospice services to deal with end of life care is in high demand. Nationally and within Oregon, rural hospices are faced with additional burdens of large square mileage areas of coverage, increased financial burden due to higher overhead costs and less Medicare reimbursement per patient, and late referrals to care with short lengths of stay. Through analysis of a physician survey about hospice experiences and interactions, interviews conducted with Hospice personnel and patients, and local and statewide annual reports for Lovejoy Hospice located in Grants Pass, OR was analyzed for its ability to address the aforementioned issues. It was found that Lovejoy Hospice through several methods such as attention to provider vs. patient locations, extensive annual fundraising, and finally a physician handbook and positive community presence and patient interaction, has addressed these problems and physician concerns with Hospice referrals and transition to care. However, through physician surveys and Hospice personnel interviews, it was identified that the transition to Hospice care could be smoother and that one are of improvement would be initiating earlier hospice planning so a plan was in place before acute patient decline. Therefore, the final product of this project was development of a patient/physician resource handout and pre-enrollment consult form providing physicians with an in-office way to initiate a conversation about end-of-life and hospice care, and brief patient epidemiology and end-of-life desires for Hospice to have on file in order to facilitate a smoother transition to Hospice care. Hospice and End of Life Care In Tillamook Project Date: 3/17/2008 Hospice care embraces a philosophy of high-quality, comprehensive end of life care. My experience in Tillamook, OR made it clear that hospice is also, in fact, a very natural extension of the strong sense of community that exists in a small town. Through a series of home visits I learned about one Tillamook woman’s experience with hospice care at the end of her life, and via interviews with hospice nurses, the hospice medical director (my preceptor) as well as other users of hospice I found that hospice care in a small town-setting may have advantages over a larger city setting, however issues remain such as reduced use of hospice in rural areas and the financial vulnerability of small hospice facilities. I also discovered that this patient’s case may actually serve as an example for a more efficient use of health care dollars in the final months of life, and as a contrast to more common spending practices in our country’s current health care system. In my five weeks in Tillamook, I was exposed to multiple end of life issues with other patients in the clinic and in the hospital, and I found that more than any previous experience in my third year, the hospice environment and our home visits to a dying patient allowed me to find greater meaning and personal solace in my interactions with these other patients. Death with Dignity - a rural community's perspective Project Date: 2/12/2007 Context: End of life care is a subject that has become more important over the last decade. “Death with dignity” is often a phrase that is used when discussing quality end of life care. However, this phrase is still not well defined. Furthermore, end of life care has been recognized as an ethical obligation of health care providers and caregivers, but this concept has not been examined from the perspectives of residents of rural communities. Objective: The objective of this project is to identify and describe elements of quality end of life care from the perspectives of residents living in the rural town of Scappoose, Oregon, as well as determining the level of awareness of advanced directives and POLST forms amongst those residents. Methods: This study is a qualitative study conducted using face-to-face interviews with open-ended questions. A total of 45 participants from 2 patient groups: clinic patients (n=28) and residents of a long-term care facility (n=17). Results: The participants identified eight domains of quality end of life care: avoiding inappropriate prolongation of dying, receiving adequate pain and symptom management, achieving a sense of control, having a peaceful and comfortable death, relieving burden, knowing that they are going to heaven, and not being alone. Overall, less than 50% of the participants in this project were aware of POLST forms. Conclusion: The conclusions drawn from this project are that the domains identified, which characterize a rural community’s perspective on end of life care, can serve as points for improving quality end of life care. Some of the values held by residents of Scappoose may also give insight as to how those residents have defined “death with dignity.” This project has also revealed the lack of awareness of POLST forms amongst the rural community of Scappoose, expressing a need for increased education regarding POLST forms and end of life care. Perspectives on end of life preparedness and POLST implementation by providers in Reedsport, Oregon. Project Date: 1/1/2007 End of life planning is an emotionally charged topic of discussion for medical personnel, patients, and families. Throughout the country, the use of heroic and expensive treatment for those with terminal conditions is the subject of debate by medical personnel as well as ethicists. End of life practices vary by hospital and certainly by demographics. This project seeks to explore the attitudes and practices of seven medical practitioners in a family health clinic in a coastal community in Oregon. The unique environment that is embodied in this town is similar to other small rural communities across the country. Reedsport has a critical access hospital that contains 22 acute care beds with accommodations for two ICU beds. It also has an extended care facility associated with the hospital. Its ER is staffed primarily by local family doctors. The family practice clinic serving this health district is located immediately adjacent to the hospital. This presents a unique opportunity to evaluate the practice and implementation of end of life measures in different medical settings by the same medical practitioners. Many if not all of the patients who are admitted to the local hospital by the ER physicians are also the patients of these same practitioners of community based medicine. Attitudes toward end of life issues were sampled by personal interview and completion of a small survey. Strategies are discussed for the increased implementation of POLST forms in the practices of these providers and in their community. "Music Therapy: what it is, what it does, and how it is used in Lebanon, OR" Project Date: 9/11/2006 “Music Therapy” is a term that has been used to define many different forms of alternative medicine practices, the most popular and studied of these being the use of live music by a Certified Music Practitioner (CMP) to ease pain, stress, depression, and anxiety. By the very nature of their health status, many patients who are chronically ill or near-to-death undergo significant stress and anxiety. This reduces their quality of life at a time when quality of life is essentially the only area left to make improvements in. While traditional medications are frequently used to make patients more comfortable, many patients and families desire a more “natural” or “spiritual” option. Music therapy can satisfy that desire. While the statistical evidence for music therapy’s efficacy is limited (like most alternative medical disciplines), the anecdotal and subjective responses to the sessions are very positive. In surveying the use of music therapy in the Lebanon/Albany/ Sweet Home area, I found that while all hospice patients in the area are offered music therapy sessions, less than 25% take advantage of the option. Of those that do, the therapy is met with an overwhelmingly positive response, with noticeable (though subjective) improvement in over half of the patients. Length of patient enrollment on Blue Mountain Hospice, The Physicians who refer patients and suggeted strategies to reduce late referrals Project Date: 3/20/2006 Blue Mountain Hospice (BMH) opened in August 2005. As with most hospices, one of its main concerns is that a significant proportion of its patients are enrolled for only a matter of a few days. The concern is that as a result, many of these patients and their families may not have time to fully benefit from the services hospice has to offer. The goals of this project were to 1) further the degree of mutual understanding between the physicians of Grant County referring patients to BMH and the staff of BMH; and, 2) provide recommendations and resources to both the physicians and BMH on possible strategies which may help to reduce late referrals. To accomplish these goals, the seven Grant County physicians were surveyed on hospice referral history, training and attitudes towards hospice, barriers to timely referral and interest in hospice related continuing education. Files of patients referred to BMH were then reviewed to characterize the population referred. Results indicated that referring physicians generally believe they are well trained in hospice, express positive attitudes towards hospice and are moderately interested in continuing education. Of the 15 patients enrolled with BMH to-date who ultimately either died on hospice (12) or were discharged (3), the median length of enrollment was 6.5 days and two patients were enrolled for only one day. Recognizing that certainly not all of the late referrals could have reasonably been avoided, recommendations and associated resources are provided to both BMH and the referring physicians with the intent that the proportion of late referrals can, over time, be reduced and more of the patients and their families can fully benefit from the unique services offered by hospice. Examining Barriers to Physician Referrals to Hospice Care in Josephine County Project Date: 2/13/2006 The goal of hospice care is to provide palliative care, symptom control, and emotional, spiritual, and social support for both patients and their families. Hospice services are meant to provide quality of life during the dying process. Lovejoy Hospice receives approximately 50% of referrals from area physicians and approximately 45% directly from families. These percentages either reflect a high public awareness of hospice services or that there are barriers for physicians when it comes to offering hospice as an option. Therefore, a survey was designed to help identify barriers in the physician community. The survey includes questions about physician and hospice interactions, the difficulties of discussing end-of-life care, the tools physicians would find helpful in an end-of-life discussion, and the awareness of the range of diseases and age groups that hospice can serve. The responses will be analyzed and, hopefully, barriers identified. With this data, strategies can be developed to aid physicians in overcoming barriers to offering patients hospice care as an end-of-life option. The desire to help physicians overcome barriers comes from the ultimate goal of ensuring that no patient goes without hospice care because the option was not presented to them. Palliative Care and Hospice Services in Coos Bay, OR: A Survey of Patient Knowledge and Opinion Project Date: 1/2/2006 South Coast Hospice (SCH) has provided hospice services to Coos Bay, OR for over 25 years. Recently a pilot program for palliative care services was begun in cooperation with Bay Area Hospital. While SCH receives feedback from patients and their families, with generally positive results, they were interested in general public opinion of hospice as well as community knowledge of palliative care. To assess this a survey of random patients within a general internal medicine practice at North Bend Medical Center in Coos Bay, OR was conducted . I also interviewed a social worker at South Coast Hospice tasked with the development of the palliative care program, which yielded information about the progress and current status of the program at Bay Area Hospital. The survey indicated that few people had heard of palliative care, and those that had thought the term was synonymous with hospice. Further, half of those surveyed have had some exposure to hospice, with the majority having had a good experience. Those without exposure were generally in favor of the program and would consider having themselves or a loved one die at own home under hospice care. Concerns about hospice were varied, but the most identifiable concern was the expected cost of hospice services. These results were forwarded to South Coast Hospice to help them address community education and other potential barriers to hospice and palliative care. RESUSCITATION STATUS IN A RURAL HOSPICE Predictors of status & ease of identifying patient preferences in emergent situations Project Date: 9/12/2005 Hospice is a growing resource in American health care that is being increasingly utilized by greater proportions of the population. In order to receive full hospice benefits, a terminal diagnosis with less than six months of expected life is required. Yet, a DNR status is not mandatory for patients who accept hospice benefits. This study attempted to identify patient characteristics that may make a hospice client more or less likely to choose a specific resuscitation status. Methodology included a chart review of 237 patients of Heart n’ Home Hospice and Palliative Care, in Fruitland, Idaho. This hospice first opened in April, 2004. The files surveyed represent all clients of this business thus far. Specific patient characteristics including resuscitation status, age, sex, hospice diagnosis and religious preference were analyzed. Additionally, impromptu hospice employee interviews provided further data concerning project limitations as well as helped to identify an area of need for which this project could serve a purpose. Though unintended during original inception, this project prompted standardization of resuscitation status within the hospice files. Therefore, the final outcome of this project is a standardized system for which emergency inquiries into a particular patient’s resuscitation status could be quickly answered. Underutilization of Hospice Services in the Treasure Valley Area: Are we referring patient too late? Project Date: 8/8/2005 OBJECTIVES: To assess utilization of hospice services in the Treasure Valley area and determine if these services are adequately being used. To determine the views and attitudes of family members and hospice care providers regarding timing of referral. SETTING: Treasure Valley including Ontario, OR, Fruitland ID, Payette ID and neighboring towns. DESIGN: Retrospective analysis of hospice patient charts and Family Evaluation of Hospice Care (FEHC) records from 2004 and 2005. In addition, hospice care providers were surveyed about the timing of referral and usefulness of services offered. PARTICIPANTS: Deceased patients at Heart’N Home Hospice and their surviving family members. Hospice staff including physicians, nurses, counselors, social workers, chaplains, home health aides, and volunteers. MEASUREMENTS: Length of time patients received hospice care, family’s opinion regarding timing of referral (too early, at about the right time, too late) and hospice providers’ perceived average length of stay on hospice and perceived optimum length of stay. RESULTS: Chart review of 126 deceased patients revealed a mean length of stay of approximately 3 weeks. 40 families completed the Family Evaluation of Hospice Care and up to 20% thought that the patient was referred too late and that lack of information was the most common reason. 80% thought that referral was made at the right time. The majority of hospice care providers who responded to the survey believe that the optimum length of stay is 6 month. In addition, most thought that patients stayed on average between 2 and 4 month on hospice. CONCLUSION: The results indicate that in the Treasure Valley area, many family members and hospice care providers feel that terminally ill patients are referred too late and that they could receive greater benefits from longer stays on hospice. The actual length of stay is consistent with that of hospice patients nationally which shows that we are in fact patients are admitted late in the process of end-of-life care. Future effort should focus on patient’s opinion of referral timing and level of awareness of referring physicians regarding prognosis and eligibility characteristics. Hopefully, this could lead to improvements in referral and admission practices. Hospitalization of Hospice Patients Project Date: 3/21/2005 OBJECTIVES: To identify reasons why hospice patients are admitted to the hospital, evaluate what treatments they receive, and identify any violations of hospice philosophy. DESIGN: Retrospective analysis of hospital charts and hospice nursing case notes from 2000 to 2005. SETTING: Newport, OR PARTICIPANTS: Hospitalized patients enrolled in Pacific Communities Hospice prior to hospital admission from 2000 to 2005. MEASUREMENTS: Specific information was gathered on each patient including: hospice admit date, hospice diagnosis, primary insurance, hospital admit date, reason for admission, route of hospital entry, length of hospital stay, treatments and procedures received in the hospital, discharge destination, date of death and place of death. RESULTS: Seven hospice patients were hospitalized between 2000 and 2005. The average age of hospice enrollment was 62 years old. Lung cancer was the most frequent terminal diagnosis. The average length of time from hospice enrollment to hospital admission was 62 days. Out of the 7 patients admitted to the hospital, 3 were admitted for pain control and 2 for seizure control. The average length of stay was 2.5 days. Three of seven patients died during their hospital stay. Various treatments were provided to these patients although one patient received the same care that had been provided at home. Two patients received peripheral IV’s. One patient received a blood transfusion. Two patients had a central line placed and a head CT. CONCLUSION: From reviewing charts of hospitalized hospice patients it appears that each admission was due to symptom management issues. Non-invasive studies performed, including head CT and EKG on 2 patients, were done to aid in symptom relief management. The invasive procedures done, which included blood transfusion and central line placement, were done to provide symptomatic relief in accordance with hospice philosophy. Delivery of and Attitudes About Hospice Care in Florence, Oregon Project Date: 3/29/2004 Hospice services are widely underutilized nationwide, despite the desire of the majority of patients to die under hospice care. With this project, I was interested in determining the current utilization of hospice services in Florence, Oregon, as well as the attitudes of the general Florence population about hospice services. The design was a written survey of random patients within a family medicine practice at Health Associates of Peace Harbor in Florence. I also interviewed the intake nurse at Peace Harbor Hospice, which yielded information about the current utilization of and services provided by the hospice program. Although there was already good penetrance of hospice within the community, the average length of stay was shorter than desired. The survey indicated that the majority of patients would prefer to die in their own home under hospice care, but that most patients were not aware of the Medicare Hospice Benefit. Opinions of hospice care by those who had known someone on hospice were overwhelmingly favorable. Concerns about hospice that might be future barriers to seeking hospice care were varied, but the most identifiable concern, especially among younger patients, was the expected cost of hospice services. These results were forwarded to Peace Harbor Hospice to better help them address the concerns of the community and to identify local potential barriers to hospice care. Patients' Views About End of Life Care in an Aging Population Project Date: 9/29/2003 Physician-assisted suicide was legally enacted in 1997 in Oregon. One year later in 1998, a survey was taken of patients in Reedsport, OR examining opinions about physician-assisted suicide. Since then, a significant demographic change has occurred, shifting the mean age of the population upwards. This project studied patients’ attitudes and knowledge base about end of life care in this aging community, including both physician-assisted suicide and hospice care. Home Health Care Options for Seniors in Philomath, Oregon. Project Date: 11/10/2003 Benton County is a community of 78,00 people with about 12% being over age 60. There are multiple nursing homes and hospice facilities available for those who need it, but there is a large population of seniors who choose to stay in their homes. Benton County is a rural community and many seniors live in isolation with few neighbors and sometimes no family. Some of the people who remain in their homes require daily medical services such as medication management, insulin injections, or wound care. More often though, they just can’t get around as well as they used to and need help with basic house keeping or meal preparation. These types of services can be managed on an outpatient basis, saving the patient and taxpayer money and allowing seniors to maintain their autonomy as long as possible. Although there are many home health services available in Benton County, not all physicians and patients are aware of them. My project was to organize all of the options for home health care into one report with some basic information about all of them, such as how they are funded and the services they offer. Respite Care in Coos Bay Project Date: 8/18/2003 Respite care continues to be an underused and misunderstood component of health care. The purpose of this project was to identify the availability of respite care resources in the Coos Bay/North Bend, Oregon community and provide information to clinicians and patients. According to an informal needs assessment of physicians in the clinic, many of their patients had caregivers or were caregivers themselves. It was also noted that these patients had increased incidence of depression, anxiety, and other symptomology such as gastrointestinal or musculoskeletal conditions. In addition to addressing these clinical concerns, physicians at the Bay Clinic in Coos Bay, Oregon wanted to address the ongoing demand of caregiving with their patients. No information on respite care was readily available to provide patients. Furthermore, the physicians themselves were unsure what was available locally or how to best answer questions on the issue. The informal needs assessment survey suggested that a compelling and comprehensive notice in rooms along with information that could be taken home would benefit clinicians and patients. An extensive review of literature, websites, and interviews with local organizations yielded an informative presentation for clinicians and patient information poster/handout. Rural Hospice Services in Benton County: A description of available services. Project Date: 3/24/2003 Hospice cares for 25% of deaths in the US. This project sought to explore hospice services available to a rural Oregon population. What is the patient population of rural hospice? What challenges does a rural hospice provider face? To answer these and other questions, the patient population of Benton Hospice, Inc., the predominant hospice provider in Benton County, was used. Home visits and nursing home visits were made with a hospice nurse, a team meeting attended, and volunteer coordinator and coordinator of patient services were interviewed. Data provided by Oregon Hospice Association of Benton Hospice allowed for comparison of statistics between Benton Hospice and Oregon state hospice populations. Results of this study revealed that Benton county hospice patients have available a wide range of services including hospice nursing, PT/OT, social work, and home health aides. Additionally, volunteer contributions are significant including massage therapists, music therapy, pet therapy, and life's history services. Benton hospice workers and administrators cite several benefits to a rural hospice program while acknowledging challenges. Benton County Hospice: Description of an Available Program Project Date: 11/4/2002 My goal was to study Benton County Hospice and their provisions of end-of-life care services to the community. I chose this topic after being introduced to the Philomath Family Medicine Clinic and realizing that the patient population includes a significant number of senior citizens. Because there is a correlation between advanced age and increased incidence of terminal illness, Philomath Family Medicine Clinic physicians often have patients admitted to Benton County Hospice. My methods to learn more about Benton County Hospice included: meeting with personnel, attending meetings, and visiting patients with a hospice nurse. Through these activities I successfully gained insight to Benton County Hospice and its vital role in the community. In addition, I came up with suggestions on how the hospice might disperse excess funds. Children and Grief: Resources for Pediatricians in Coos County Project Date: 2/11/2002 Children grieve according to their developmental stage and individual personalities. There is no "right" way to grieve and each child will go through the process in their own way. Pediatricians can be a vital source of support and information for families dealing with the loss of a loved one. In Coos County pediatricians also have the additional resource of the Light House Center, a support program for grieving children, teens, and families. Working with the Family Services Manager, I developed an educational and fund-raising presentation as a service to the Light House Center and the pediatricians of Coos County. Financial Implications of Early Death to South Coast Hospice Project Date: 3/25/2002 At South Coast Hospice, reimbursements from Medicare and private insurance are insufficient to meet patient expenses by approximately 300,000 dollars a year. As a result, South Coast Hospice(SCH), like many other hospices relies heavily on grants and fundraising to meet expenses beyond reimbursement. For this project, data from SCH was used to calculate death trends and their financial impact on SCH. This information was then presented to area physicians along with studies suggesting ways to make hospice financially independent of grants and donations. The results of the data showed that 31 percent of all patients admitted to SCH die within seven days. Eight percent of patients desiring hospice die before admission. The median length of survival from the time of admission is 17 days. Meanwhile, patients who die within seven days cost 3 times as much to care for when compared with those living beyond 17 days. As a result, Medicare's reimbursement plan of $116.40 per patient per day makes patients who die early unaffordable. State data shows that for hospice to break even, patients must be enrolled in hospice for at least 33 days. Besides presenting the financial data of hospice to physicians, multiple prognostication studies were reviewed which suggest that poor prognostication contributes to the financial deficit of SCH. Physicians overestimate time to death by a factor of 3-5. In addition, prognostic information is frequently withheld, leading to unrealistic patient expectations and delayed hospice admission. Experts suggest that open communication and early discussion of hospice with patients, even with those who have a good prognosis, can improve patient satisfaction, facilitate earlier hospice admissions, and reduce the reliance of hospice on grants and donations. Back to subject search page or search by preceptor site