November 17, 2020
Landmark’s Patient-Centered Approach to Palliative Care
A case study on Landmark's palliative care model.
Palliative Care at Landmark
Landmark provides palliative care to patients with chronic illnesses. Landmark’s multi-disciplinary care team works with patients to develop a palliative care plan that reflects the patient’s priorities. They discuss:
- The patient’s goals and fears
- Symptom management
- Illness progression and treatments
- Interventions that the patient would or would not want to receive
- Emotional support for patient and caregivers
- Transitions across care settings
Providers, behavioral health specialists, social workers, dietitians and more are all available to Landmark patients to create a well-rounded, patient-centered palliative care plan.
Palliative Care Case Study
An 86-year-old female patient has a history of hypertension and osteoporosis, with multiple spinal compression fractures contributing to frequent intermittent painful episodes. She has had several falls in the past two years, requiring hospitalizations, surgery and live-in care to help her with personal needs. She doesn’t wish to have aggressive lifesaving procedures but does want to return to the hospital if her needs cannot be met at home. She has a daughter who lives close and is very involved with her care, but the patient is still paying her bills and is active at the senior center.
Before Palliative Care
- Patient sees her primary doctor twice a year for check-ups.
- She has frequent emergency room visits after each fall.
- Her daughter is concerned about risk of falls in her mother’s home.
- Patient is anxious over wanting to remain independent for as long as possible.
With Palliative Care
- Landmark provider visits patient at home to evaluate her medical conditions and medication regimen. The provider discovers medications that may be contributing to her risk of falls that may need to be stopped.
- Provider orders physical and occupational therapy to come to the home to help improve her strength and to evaluate for factors contributing to falls.
- Provider reaches out to patient’s primary care provider to coordinate care.
- Landmark social worker and provider visit patient and her daughter to discuss the patient’s values and goals. She expresses that she wants to remain home independently for as long as possible.
- Patient receives a special fall-alert device that alerts Landmark if and when a patient should fall. It allows the patient to communicate directly with Landmark upon pressing the device.
- Social worker identifies that patient would benefit from additional help in her home in the mornings and helps set up the service.
- Patient and her daughter feel assured that Landmark is available 24/7 for any urgent issues.