Coordination of Care of Chronic Illness Palliative Care Services Early Stage Middle Stage Late Stage Goals of Care Discuss diagnosis, prognosis, likely course of the illness, and disease-modifying therapies; talk about patient-centered goals, hopes, and expectations for medical treatments. Discuss diagnosis, prognosis, likely course of the illness, and disease-modifying therapies; talk about patient-centered goals, hopes, and expectations for medical treatments. Review patient’s understanding of prognosis; review efficacy and benefit-to-burden ratio for disease-modifying treatments; reassess goals of care and expectations; prepare patient and patient’s family for a shift in goals; encourage paying attention to important tasks, relationships, and financial affairs. Assess patient’s understanding of diagnosis, disease course, and prognosis’ review appropriateness of disease-modifying treatments; review goals of care and recommend appropriate shifts; help patient explicitly plan for a peaceful death; encourage completion of important tasks and increased attention to relationships and financial affairs. Programmatic Support Advise patient to sign up for visiting nurse and in home services and case management services (if available). Advise patient to sign up for visiting nurse and home services; consider palliative care program in hospital or at home, hospice, sub acute rehabilitation, case management services. Advise patient to sign up for a palliative care program in hospital or at home, case-management services, hospice; consider nursing home placement with hospice or palliative care if patient’s home caregivers are overwhelmed. Financial Planning Advise patient to seek help in planning for financial, long-term , and insurance needs and to begin transfer of assets if patient is considering a future Medicaid application; refer patient to a lawyer who is experienced in health issues. Advise patient to reassess adequacy of planning for financial, medical, home services, prescription, long-term care, and family-support needs; consider hospice referral and Medicaid eligibility. Advise patient to review all financial resources and needs; inform patient and family about financial options for personal and long-term care (e/g/, hospice and Medicaid) if resources are inadequate to meet needs; explicitly recommend hospice and review its advantages; consider Medicaid eligibility. Family Support Inform patient and family about support groups; ask about practical support needs (e.g., transportation, prescription-drug coverage, respite care and personal care); listen to concerns. Encourage support or counseling for family caregiver; ensure that caregivers have information about practical resources, stress, depression, and adequacy of medical care; identify respite and practical support resources; recommend help from family and friends; raise the possibility of hospice and discuss its benefits; listen to concerns Encourage out-of-town family to visit; refer caregivers to disease-specific support groups or counseling; inquire routinely about health, well being, and practical needs of caregivers; offer resources for respite care; after death, send bereavement card and call after one or two weeks; screen for complicated bereavement; maintain occasional contact after patient’s death; listen to concerns The New England Journal of Medicine R. Sean Morrison, M.D. & Diane E. Meier, M.D.