Last week you may have seen my blog post, if you didn’t you can check it out here: Private Duty, Home Health and Hospice Owners: Want to grow your agency? Then Change your delivery model!  I promised you last week that I would teach you the steps to build a Total Patient Care Delivery Model and I will.

We talked about Sam and what happens when we each operate in a silo and just provide the patient and their family the services that we do so well. Unfortunately, that leads to patients that aren’t being delivered appropriate services such as private duty care, home health, or hospice services. That level of inferior care stops now! Let’s all develop a Total Patient Care Delivery Model.

Let’s do a brief visualization.

Just Imagine if we made just a few modifications to our current patients on our census plan of care.

First, the home care agency (private duty) notified hospice at start of care, that they have admitted a new patient and would like to have palliative services added to the patients plan of care.

Now patient can be seen once a month from someone from the hospice organization. This will allow for the hospice to identify and jump into action as soon as the patient becomes eligible for hospice services.

…Or Imagine if the private duty home care agency notifies a home health partner about non-healing wound related to the patient having a fall in home. Home health then gets visiting physician to see patient for a face-to-face encounter, and the patient goes on home health for wound healing.

The home health agency can also refer the patient to hospice to make a visit to see patient monthly. At the time that patient presents appropriate signs, the patient is then admitted to hospice services and discharged from home health.

If we all work together, the patient and the patient’s family have a better experience. The patient’s daughter gets a much-needed break and uses her 5 days of respite stay and pays for 2 more days privately while she visits her grandchildren. Patient receives 5 months on hospice services, which includes pet therapy. Mr. Sam loved dogs and this always improved his mood. The daughter loves to see her father so happy!

Hospice created an incredible life journey book, filled with stories and pictures of the patient’s life that was given to his daughter at her first bereavement visit. Sam’s daughter is feeling supported and at peace with her father passing away so comfortably in his own home.

It is time for us to escape the creation of patient care plans in a silo. It is time that we understand what each of us can do to make a total patient care delivery model. We can become real post-acute care experts! We have some of the smartest people in the industry reading this blog post right now. We each have an obligation and an opportunity to serve others to a higher level if we can just figure out how to work together to support our patients and their families. So many of us don’t even know what hospice provides!

I’m sure many of you would be shocked to know that hospice includes covering for all medications related to the terminal illness.

This includes incontinence products and nutritional supplements like Ensure or Glucerna. Hospice includes social services and spiritual counseling, as well as incredible programs to help dying patients leave a legacy.

Together is where we can provide care that is patient centered and family centered! So right now, I want all of you to think about who can you partner with? What Home Care Private duty agency is getting noticed in each of your service markets? What Home Health Provider has a large census and an excellent star rating? What hospice company in your area has the best reputation and a high patient census that can refer to your organization?

Once you have selected the providers you want to target, send them a letter about starting a Total Patient Delivery Model and looking for partners to work with.


Review the following:




Meet with your other potential post-acute partners and see if they are a good fit. This is your chance to build a process to share referrals and communicate about weekly admits so together you can build your total patient delivery model plan of care!


By Cheryl Peltekis, RN “The Solutionist”