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Hospice residence project

ProQuest Dissertations and Theses, 2011
Dissertation
Author: Sylvia Blakeman
Abstract:
Terminally ill patients unable to remain in their own homes must live their final days and hours in the acute care hospital or area nursing homes whose primary focus is to cure, rehabilitate, or maintain optimum function rather than to provide skilled and compassionate end of life care. Pain is generally under treated, symptoms are often not well managed, and choices are seldom offered. A hospice residence provides a place of peace, comfort, and specialized care for the dying in a homelike setting. Lakeview Medical Center (LMC) hospice patients do not have access to these services because there is no hospice residence in northwest Wisconsin. The purpose of this DNP project is to provide evidence of need, supporting rationale, and a business plan to guide LMC in the development of a residential hospice program. The recent acquisition of LMC by Marshfield Clinic (MC) offers opportunities to enhance a variety of healthcare services including a seamless end of life care continuum, fulfilling the mission of both organizations to expand access to all types of quality health care. However, actual implementation of the plan will be a lengthy process consisting of several developmental phases beyond the scope of this DNP project.

Table of C ontents

Dedication

................................ ................................ ................................ ................................ ...

iii

Acknowledgements

................................ ................................ ................................ .....................

iv

Abstract

................................ ................................ ................................ ................................ ......... v

Chapter I: Executive Summary

................................ ................................ ................................ ..... 1

Statement of the Problem

................................ ................................ ................................ .. 1

Problem of the Study

................................ ................................ ................................ ........ 2

Purpose of the Proj ect in Relation to the Problem

................................ ............................ 5

Significance for Healthcare Outcomes

................................ ................................ ............. 6

Cost Benefit Analysis

................................ ................................ ................................ ..... 11

Theoretical

Rationale Guiding the Project

................................ ................................ ...... 13

Models and Frameworks Guiding the Project

................................ ................................ 19

Identification of St akeholders and Project Mentor

................................ ......................... 23

Summ ary

................................ ................................ ................................ ......................... 25

Chapter II: Review

of Literature

................................ ................................ ................................ 26

Literature Related to T heoretical Rationale

................................ ................................ .... 26

Literature R elated to Models and Frameworks Guiding the Project

.............................. 32

Literature Related to the Purpose of the Project

................................ ............................. 38

Summary

................................ ................................ ................................ ......................... 45

Chapter III: Implementation

................................ ................................ ................................ ....... 47

Project Goal

................................ ................................ ................................ .................... 47

Project Objectives

................................ ................................ ................................ ........... 47

Mission Statement

................................ ................................ ................................ ........... 49

vii

Setting and Population

................................ ................................ ................................ .... 49

Ou tcome Data Collection Process

................................ ................................ .................. 50

Budget to Produce the Business Plan ................................ ................................ .............. 53

Leadership

................................ ................................ ................................ ....................... 53

Barriers/Unanticipated Events

................................ ................................ ........................ 54

Summary

................................ ................................ ................................ ......................... 55

Chapter IV: Project Results

................................ ................................ ................................ ........ 57

Process Analysis

................................ ................................ ................................ ............. 57

Findings Related to Expected Outcomes

................................ ................................ ........ 57

Findings Related to System Change

................................ ................................ ............... 71

Dat a Collection

................................ ................................ ................................ ............... 74

Measures

................................ ................................ ................................ ......................... 74

Statistic al Analysis – Quantitative Data

................................ ................................ ........... 74

Timeline

................................ ................................ ................................ .......................... 75

Chapter V: Project Summary

................................ ................................ ................................ ...... 77

Discussion of the Findin gs and Outcomes

................................ ................................ ...... 77

Reco mmendations for System Change

................................ ................................ ........... 79

Fee Structure

................................ ................................ ................................ ................... 80

Process Directly Related to Outcomes as the Result of Receiving Services

at the Residence

................................ ................................ ................................ .. 81

Relationship of the Project to DNP Essentials

................................ ................................ 81

Conclusions

................................ ................................ ................................ ..................... 82

Plan

for Dissemin ation of Results ................................ ................................ ................... 82

viii

References

................................ ................................ ................................ ................................ ... 84

Appendices :

A .

Permission to Apply Feasibility Test for Corporate Vision

and Feasibility

Test Scoring Results

................................ ................................ ................................ . 93

B.

Proforma

................................ ................................ ................................ ................... 96

C .

Quick Facts Demographic

Information on Counties in the Lakeview

Medical Center Hospice Service Area

................................ ................................ ...... 98

D .

Community Hospice House Needs Survey Tool

................................ .................... 102

E .

Hospice Residence Benchmark Tour

Findings S tructured A round

Leibhaber and Bader ‘ s (2002) Guiding Principles

................................ ................. 104

F.

Architect ‘s

Cost Projection , Space N eeds, and Plan Cost Estimate

....................... 128

G.

Marketing Plan

................................ ................................ ................................ ........ 135

H.

Capital C ampaign Fundraising Plan

................................ ................................ ....... 137

I.

Hospice Residence Logic Model

................................ ................................ ............ 139

ix

List of Tables

Table

Page

1.

Ten Carative Factors

................................ ................................ ................................ ........

14

2.

Watson‘s Clinical Caritas Processes

................................ ................................ ................

15

3.

Identification of Stakeholders

................................ ................................ ..........................

24

4.

Processes and Timelines

................................ ................................ ................................ ..

51

5.

Budget to Produce Business Plan

................................ ................................ ....................

53

6.

Community Hospice House Needs Survey Results

( N =73)

................................ ............

59

7.

Feasibility Test for LMC

Corporate Vision Scoring

................................ .......................

69

8.

Hospice Residence Outcome Survey Results Example

................................ ...................

75

1

Chapter I:

Executive Summary

Statement of the Problem

Problem: There is a gap in service delivery for Lakeview Medical Center ( LMC )

hospice patients who cannot remain in their own homes to receive end of life care. They must go to a nursing home or acute care hospital where the treatment focus and goals do not align with the hospice philosophy. Pain and symptoms are generally not we ll managed and often patients experience an uncomfortable and painful death.

Purpose: The purpose of t his DNP project is to provide information and rationale to facilitate momentum in hospice residential development for LMC and Marshfield Clinic (MC).

Goal : The goal of this DNP

project is to create a business plan to guide the organization in decision making and planning as they move forward in their commitment to providing a seamless continuum of quality end of life care.

Objectives: The objectives of this

project are to implement strategies necessary to demonstrate need, obtain information, and develop a business plan.

Project Results: The objectives were achieved over a period of three years of seeking information from the literature, existing hospice r esidences, interviews, and surveys.

Recommendations: The next step is f or LMC and MC to make a final decision to move forward with the development and construction of the hospice residence. Follo wing this decision, a professional consultant should be re tained to conduct a financial feasibility study to determine the amount of readiness and support the organization can expect from the local community.

Based on the results of the study, project designs and budget should be developed and plans for a capita l campaign should be initiated.

2

Problem of the Study

LMC

currently provides hospice services in patient homes as well as in hospice contracted nursing homes. However ,

many of the patients cannot remain in their own homes to die and must be transferred to the hospital or nursing home because there is no residential hospice in this community. For these patients, the continuum of quality end of life care is disrupted because they are denied the experience of specialized care and a peaceful death in the homel ike setting of a hospice residence.

Although care in these alternative settings is provided by well meaning staff, service priorities are focused on cure, rehabilitation, or maintenance of optimum function.

Despite education and support by hospice staff,

pain and symptoms are not consistently well managed due to lack of understanding of the hospice philosophy and the spe cial needs at the end of life.

The National Hospice and Palliative Care Organization (NHPCO , 2009 ) describes

hospice as a program that he lps patients and their families work through the dying process by providing education, care, and support. Hospice helps with managing the patient‘s symptoms as well as with the variety of emotional issues that develop.

Hospice care is designed to provide

specialized, compassionate care at the end of life. It consists of comfort measures as opposed to curative car e and is meant to serve individuals with a life lim iting disease (NHPCO, 2009).

The goal of hospice is to provide quality compassionate care for patients and families facing a terminal illness. Patients continue to receive medical care focused on achieving freedom from pain to obtain the highest degree of comfort possible. The hospi ce population includes patients of all ages with a terminal illness and a predictable course leading to death, typically within six months or less. Patients who choose hospice have decided to accept only comfort measures in their last days. Hospice care is patient driven medicine, meaning that the

3

medical care of hospice patients is individualized ,

not by physicians, but by the patient‘s desires.

Every accommodation is made to preserve the autonomy, dignity, and desires of dying patients receiving hospic e services (NHPCO, 2009).

Hospice focuses on education for patients and families regarding expected outcomes during one‘s last days including clarification of life sustaining measures versus comfort measures. Along with this, psychosocial needs are suppor ted by not only allowing the patient to live as full a life as possible, but also allowing family members respite so that they may be less overwhelmed by the care of a loved one at the end of life. Spiritual needs, emotional needs, and practical needs are

also addressed (NHPCO, 2009).

Although hospice care is most often provided in the patient‘s home, there are situations where a patient may live alone, the caregiver is no longer able to provide care, or there is an unsafe home environment and other housin g options must be considered.

A hospice residence is a peaceful and comfortable alternative to a nursing home, assisted living ,

or hospital setting.

While there is no single definition of a residence, it could be purposely designed and constructed or ada pted, modified ,

or remodeled to become a residence (Liebhaber & Bader, 2002).

The term ―residence‖ is meant to define something different from a designated unit in a hospital or nursing home. While not generally intended to serve as a permanent long - term

housing solution, a residence is designed to care for terminally ill patients who for whatever reason cannot remain in their own homes (Murray, 2004).

Each organization needs to define and determine the level of services, admission, and continued stay cr iteria are appropriate for their setting. It could, however, offer various levels of hospice services, depending upon licensing and building code requirements. A residence might offer only hospice routine care services and respite care, or it might offer

these services in conjunction with general inpatient hospice care.

4

Dr. Cicely Saunders (1996), responsible for establishing St. Christopher‘s Hospice in L ondon in 1967, wrote of a dying cancer patient who she believes

is the real founder of the modern ho spice residence concept. As this patient approached death , he told Dr. Saunders

that he wanted what was in ―her mind and heart ,‖ meaning he wanted more than just care of his physical needs (Saunders, 1996, p.

318). He was seeking care of his psychosocial and spiritual needs as well. His comments led Dr. Saunders to the realization

that dyi ng patients need friendship and compassion

as well as expert clinical care. This patient included a financial donation in his will to ―be a window in your home‖ which c ontributed to the beginning of Dr. Saunder‘s mission and the worldwide hospice movement

(Saunders, 1996, p. 318). Home referred to a place where people could experience space and openness, unavailable to this dying patient in the busy surgical ward. His reference to a window led Dr. Saunders to a realization that ―we should be open to and from the world, to all who would come; patients, families and those who wanted to learn‖ (Saunders, 1996, p. 318).

Avedis Donabedian, famous for the development of qual ity healthcare systems assessment, experienced hospitalization during his terminal illness. He found hospital quality, though generally favorable, was primarily focused on technical competencies rather than interpersonal competencies.

Systems awareness and system design are not enough…

Ultimately; the secret of quality is love. You have to love your patient, you have to love your profession, you have to love your God. If you have love, you can then work backward to monitor and improve the system . (Mu llan, 2001, p. 42)

Although expert technical competencies are staff requirements in residential hospices, the interdisciplinary team design assures a compassionate yet comprehensive delivery and quality approach to end of life care.

5

Hospice residences thr oughout the nation are not only reaching out to those dying individuals in need, but are increasing visibility and public awareness of the hospice movement and the availability of quality end of life care.

Research results show that aging individuals want

to receive good care as they approach death and wish to avoid burdening their families (Kahana, 2010). Hospice patients are generally transferred to facilities as their condition deteriorates because they can no longer be cared for in their home. Their experience can be improved by assuring that unique, individualized care, and treatment wishes are respected and provided in a pleasant physical environment.

Evans, Cutson, Steinhauser, and Tulsky (2006) interviewed caregivers of deceased hospice patients t o determine reasons for home hospice patient transfers to inpatient facilities such as hospitals, hospice residential facilities, and nursing homes.

The researchers also inquired about the transfer experience and site of care preference. The main reasons for transfers included acute care needs, pain and symptom management, and inability to continue to provide care in the home setting.

Caregivers reported that p atients transferred to a hospice facility found high level care, provided by experienced , compassionate staff in a physically pleasing, homelike setting. Caregivers often stated they had wished they had come sooner and those who returned home wished they could have stayed longer. Some patients and caregivers preferred the hospice facility a s the place of death over home. Others stated home held too many reminders of life, or that the death would bring back unpleasant memories in the future. Many stated the hospice felt like home

(Evans et al., 2006).

Purpose of the Project i n Relation t o t he Problem

The purpose of this project is to develop a business plan for the future construction and operation of a hospice residence in Rice Lake, Wisconsin. Such a hospice residence will

6

contribute to the quality end of life care continuum for terminal ly ill patients who can no longer remain in their own homes or need short - term placement for respite or pain and symptom management. Care is provided by a highly qualified team specifically educated in the hospice philosophy and best practices defined by the NHPCO

as the Gold Standard in end of life care services (NHPCO, 2004). Patients benefit from the frequent assessment and adjustment of medications to treat pain, respiratory distress, nausea, fatigue, and weakness. Spiritual and psychosocial needs ar e also addressed to provide comprehensive caring of the mind, body, and spirit. Team members are committed to providing coordinated, quality pain and symptom management while supporting and enhancing the family experience through social services, spiritua l care services, and specially trained hospice volunteers.

Currently, LMC hospice patients must be transferred from their homes to the acute care hospital or nursing home where the primary focus is curative treatment, rehabilitation, or optimal function m aintenance. Generally workers in these settings do not have knowledge of or understand the hospice philosophy, are rushed, and are assigned responsibilities of numerous patients. These institutional settings are not designed to provide a homelike atmosph ere and seldom offer serene peace and quiet (Munn & Zimmerman, 2006).

Significance for Health c are Outcomes

Hospice patients primarily receive care in their own home where a family member is generally the primary care provider. However, sometimes there is

no caregiver or situations reach the point where the family member can no longer provide the degree of care and support required. A hospice residence is designed to meet the dying individual‘s care needs in a peaceful, homelike environment (Snyder & Emer son, 1991).

7

Elderly caregivers generally have a difficult time managing the care of the terminally ill due to limited resources, endurance, and their own health issues.

Care giving

often impacts employment forcing a family member to quit a job or take a medical leave to care for the terminally ill family member, reducing needed income. The demands on the family are not exclusively monetary but are also physical and mental. Physica l stress involves lifting, carrying, and turning a patient as well as losing sleep or having sleep interrupted. Caregiver emotional stress is a major problem in providing end of life care and many families find they are not able to cope with these pressur es on a long - term basis (Snyder & Emerson, 1991).

Often patient homes are not spacious enough to accommodate hospital beds, wheelchairs, lifts, oxygen equipment, and medical supplies. Many older private homes were not constructed to be handicapped accessi ble resulting in doors too narrow for wheelchair navigation or bathrooms too small to accommodate both the patient and caregiver. In some situations, the home environment is not suitable for patient care due to safety issues, lack of cleanliness, lack of basic plumbing, overcrowding, and family dysfunction.

Individuals living alone face the previously described physical obstacles and environmental concerns in addition to the often extreme symptoms of pain, nausea, and general debility as their condition deteriorates. In the absence of a willing and able caregiver they are at increased safety risks and unable to meet basic needs (Snyder & Emerson, 1991).

A hospice residence also contributes to a seamless hospital - hospice continuum of care by offering an a ttractive location for transitional care for patients who may be able to be discharged from the hospital but cannot return home for a variety of reasons. For example, when families are not ready to provide care or need additional education and assurance, staff members will

8

work with the family to teach what they need to know to provide care and build confidence before taking their loved one home.

When the patient‘s home support system has broken down, the environment is unsafe, or the family is unable to provide care, the residence provides a homelike atmosphere in which the patient receives compassionate, quality end of life care and comfort. Terminal care is also offered when the patient‘s condition starts to rapidly deteriorate and the patient and fami ly do not feel comfortable remain in g at home. As patient symptoms are managed and comfort is maintained, caregivers and family members are relieved of the stress of providing care. As the patient‘s condition declines, family and friends receive staff sup port and the opportunity to spend quality time with their loved one.

The proposed hospice residential program will offer safe, compassionate, specialized, end of life care services provided by the hospice interdisciplinary team including the medical direct or, registered nurses and nursing assistants certified in hospice and palliative care, social workers, and hospice volunteers. Services will be provided in a clean, quiet, peaceful, homelike setting.

Specially trained hospice volunteers and an array of s ervices will be available as well as bereavement aftercare and community bereavement support groups.

In addition to patient care services and family support, the hospice residential program will offer opportunities for community end of life education as w ell as serve as a nursing and medical student clinical site.

An early, positive, professional experience in caring for dying patients is believed to be effective in ensuring successful future end of life care and coping skills. A group of researchers stu died nurses‘ experiences of grief following the deaths of their patients

(Gerow

et al. , 2010). They found that nurses who had positive end of life care experiences were more likely to successfully care for their dying patients as well as manage feelings o f loss and

9

grief than nurses who had negative experiences. Implications for improving these experiences through a supportive atmosphere and demonstration of effective coping skills should be used to assist and teach other nurses (Gerow

et al. , 2010). A h ospice residential program will provide a supportive, educational environment conducive to teaching, mentoring, and role modeling quality end of life care.

There are several area nursing homes currently available for longer - term placement.

However, while the nursing home goal is to provide the highest quality restorative or maintenance care possible, strict regulatory requirements and limited resources significantly challenge the ability to meet this goal.

Caregiver staff members typically are assigned nu merous residents and rotate on a shift basis making continuity of personalized care more difficult.

Research reveals that nursing home residents are not always treated with respect and often pain and symptoms are not well managed

(Bernabei

et al., 1998; T eno et al. ,

2004).

Staff members working in these facilities receive brief in - services on the hospice philosophy and end of life care but are found to be more focused on cure or maintenance of achieved optimal function rather than compassionate care and co mfort. Also, nursing personnel in these settings have not received specialized education in pain and symptom management which often results in under treated

pain, poorly managed symptoms, and lack of respect for dignity, comfort, and tranquility ( Center t o Advance Palliative

Care

[CAPC] , 200 8).

Nursing homes care for large numbers of residents and typically have the look and feel of

an institution rather than a home environment. The basic configuration of a semi - private room or private room off a hallway is the same in most nursing homes. The patient passes the time either in their room or in a lounge - type common area typically on the same floor. While patients

10

usually have the ability to add items from home and arrange the room to provide more homelike surroundings, the environment remains institutionalized

( Lie b haber & Bader, 2002).

There are 17

Wisconsin hospice residences primarily located in the southeastern section of the state. The nearest Wisconsin hospice residence is House of the Dove located in Marshfield, Wisconsin, 128 miles east of Rice Lake. Patients, families, and community member s

often ask the LMC hospice staff members why the organization does not have a hospice residence. During the 2008 annual hospice agency request and presentation to the Rice Lake United Way Committee, I was questioned as to why there is no hospice residenc e in Rice Lake. These questions offer an opportunity to provide education and information about hospice and the benefits of a hospice residence.

Many community members, patients, and patient families have expressed their willingness to help and support s uch an endeavor when LMC is ready to develop a hospice residence program. Small scale hospice house surveys have also revealed positive support for the development of a hospice residence in the Rice Lake community.

After LMC‘s two - year struggle to maintai n independence, MC, a large national private clinic system, acquired LMC on April 1, 2008. Since that time, the affiliation, as it is commonly termed by both organizations, was implemented in phases. The final phase was completed in July 2011 when all LM C staff members were officially converted to the MC system as MC employees.

The affiliation is intended to enhance the opportunities of a combined medical center in offering expanded care to residents living within the service area.

The mission statement for MC is to ―serve patients through accessible, high quality health care, research and education ‖

( MC , 2011 , n.p. ). LMC‘s mission is to ―enhance the health of the communities we serve‖ ( LMC ,

11

2011 , n.p. ). Offering a seamless continuum of quality end of l ife care fulfills the mission of both organizations regarding accessible, quality care in all stages of health through improved services. LMC‘s promise is

to provide the care you need, when you need it, close to home. To fulfill that promise, we‘re comm itted to investing in the personnel, technology an d facilities necessary to meet your health care needs now and well into the future .

( LMC , 2011 , n.p.)

This mission and vision aligns with the purpose and philosophy of the hospice residential concept in o ffering a place of peace and comfort for dying individuals in this community.

Cost Benefit Analysis

Candy, Holman, Leurent, Davis, and Jones (2011) found there is evidence supporting the benefits of hospice care related to patient and family satisfaction.

Their study also revealed reduced health service utilization and costs, an increase in effective pain management, and the decreased likelihood of hospitalization. However, in their literature review, Candy et al. (2011) discovered methodological limitat ions in the evaluations of clinical benefit and cost effectiveness and therefore determined that generalized assumptions should not be applied to the overall impact of hospice services. Candy et al. (2011) suggest further research of hospice services in a ll settings to gain a more standardized approach and evaluation of cost benefit analysis applicable to the variety of hospice care delivery systems.

Six years prior, Biskupiak and Korner (2005) identified the need for further study to reach beyond measure ments of cost savings by improving methodologies assessing the cost effectiveness in all variations of hospice care delivery.

Although the cost of hospice residence development, construction, implementation, and operation is significant, there are organiza tional benefits and potential cost savings to consider aside from providing the right care at the right time in the right place. Not only can there be a seamless continuum of hospice care and increased patient, family, and staff satisfaction, but also

12

the

additional benefit of providing quality care to patients who would otherwise be hospitalized or discharged to a nursing home. Terminally ill patients needing pain and symptom management are sometimes brought to the LMC emergency department by frantic and

exhausted caregivers unable to continue to care for their loved one.

Rather than a hospital admission, these patients can be offered residential hospice services avoiding the possibility of uncomfortable and costly diagnostic tests as well as keep ing

acu te care beds available.

In other instances, terminally ill LMC hospitalized patients are stable enough to be discharged but do not want to leave the hospital.

These patients, loved ones, and staff members struggle with the difficult decisions and outcomes

involved with nursing home placement. In these instances, LMC patients and family members express their frustrations and dissatisfaction with services, reflecting negatively upon the entire organization. Such negative experiences can also affect their p ersonal choice in future healthcare providers as well as future choices of family and friends. Providing excellence in care and environment to dying loved ones can be helpful in attracting potential LMC healthcare consumers as well as retaining current us ers of LMC services.

Providing the physical presence of a hospice residence also creates visibility helping to increase awareness and knowledge of the availability of hospice services.

This presence ,

along with strategic marketing and community/provider educational efforts ,

can promote earlier hospice referrals to help in decreased hospitalizations and acute care bed utilization. Earlier referrals can also increase the hospice census ,

meaning that mo re terminally ill patients and their families are receiving the care and support sooner in their end of life journey than would be the case if there were no hospice residential program.

13

Finally, the most important factor in offering a hospice residential c are option is the fulfillment of the moral obligation to provide dignity and comfort at the end of life to those who cannot remain in their own homes. Dying is part of living yet remains a mystery, coming to everyone as a unique, personal experience. The

expectation that one will be cared for in a reliable, humane, and effective manner should be fulfilled ( Institute of Medicine [ IOM ] , 1997).

Theoretical Rationale Guiding the Project

Jean Watson’s theory of human caring . Jean Watson‘s caring theory captu res the essence of the hospice philosophy based on the carative factors and values of preserving human dignity and humanity in the healthcare system. The scope of the theory encompasses the entire health - illness continuum from illness prevention to a peac eful death (Barnhart, Benne t t, Porter, & Sloan, 1994).

The caring emphasis is directed to the enhancement of interpersonal and transpersonal relationships while maintaining harmony in mind, body, and soul (Watson, 1985). Transpersonal caring values conne ctedness, relationships, subjective meaning, and shared humanity, conveying a connection beyond ego to spiritual dimensions (Watson, 2002). ―Nursing has a critical role in moving humanity toward the omega point, ever closer to God and the mysterious sacre d circle of living, trusting, loving, being, and dying‖ (Watson, 2003, p. 202).

Full document contains 150 pages
Abstract: Terminally ill patients unable to remain in their own homes must live their final days and hours in the acute care hospital or area nursing homes whose primary focus is to cure, rehabilitate, or maintain optimum function rather than to provide skilled and compassionate end of life care. Pain is generally under treated, symptoms are often not well managed, and choices are seldom offered. A hospice residence provides a place of peace, comfort, and specialized care for the dying in a homelike setting. Lakeview Medical Center (LMC) hospice patients do not have access to these services because there is no hospice residence in northwest Wisconsin. The purpose of this DNP project is to provide evidence of need, supporting rationale, and a business plan to guide LMC in the development of a residential hospice program. The recent acquisition of LMC by Marshfield Clinic (MC) offers opportunities to enhance a variety of healthcare services including a seamless end of life care continuum, fulfilling the mission of both organizations to expand access to all types of quality health care. However, actual implementation of the plan will be a lengthy process consisting of several developmental phases beyond the scope of this DNP project.