Starting and Sustaining Palliative Care in Public Hospitals: Lessons Learned from a Statewide Initiative.

BACKGROUND: Compared with private, not-for-profit hospitals, significantly fewer public hospitals report that they provide palliative care services for their patients. Because uninsured and underinsured patients largely depend on public hospitals for acute medical care, they therefore experience disparities in access to inpatient palliative care services. To address this disparity, the statewide Spreading Palliative Care in Public Hospitals Initiative (SPCPHI) was established to help implement or expand inpatient palliative care services in all 17 of California's public acute care hospitals. AIM: The aim of this article is to use the experiences from the SPCPHI to describe the unique challenges to providing palliative care in public hospitals; the major barriers to initiating, growing, and sustaining palliative care programs in public hospitals; and the common solutions to overcoming those barriers. CONCLUSIONS: Palliative care programs in public hospitals must develop the necessary skills and staffing to meet the complex needs of vulnerable patients and their families. These programs face a variety of unique organizational and operational challenges such as limited and uncertain funding, limited access to hospital data and analytic support, and complex regulatory structures, which may hinder growth of palliative care in these systems. Experiences from the SPCPHI suggest that networking, technical assistance, and startup funding are helpful to overcome these barriers and to develop high-quality, sustainable palliative care programs in public hospitals.

Reflections on a decade of funding public hospital systems.

As the nation embarks upon health reform, many questions remain unanswered. Important among them is the fate of public hospitals, which have historically cared for the uninsured. Under health reform, public hospitals will face marketplace competition to serve newly insured people. Can public hospitals change, so that they can survive and thrive in a competitive environment? This article describes lessons learned from a decade of funding by the California HealthCare Foundation to improve clinical care in California's public hospitals. It also identifies factors that will influence California's public hospitals in the coming months and years.

A multifaceted approach to spreading palliative care consultation services in California public hospital systems.

Historically, California's 17 public hospital systems-those that are county owned and operated, and those University of California medical centers with the mandate to serve low income, vulnerable populations-have struggled to implement Palliative Care Consultation Services (PCCS)-this, despite demonstrated need for these services among the uninsured and Medicaid populations served by these facilities. Since 2008, through a collaborative effort of a foundation, a palliative care training center, and a nonprofit quality improvement organization, the Spreading Palliative Care in Public Hospitals initiative (SPCPH) has resulted in a 3-fold increase in the number of California public hospitals providing PCCS, from 4 to 12. The SPCPH leveraged grant funding, the trusted relationships between California public hospitals and their quality improvement organization, technical assistance and training, peer support and learning, and a tailored business case demonstrating the financial/resource utilization benefits of dedicated PCCS. This article describes the SPCPH's distinctive design, features of the public hospital PCCS, patient and team characteristics, and PCCS provider perceptions of environmental factors, and SPCPH features that promoted or impeded their success. Lessons learned may have implications for other hospital systems undertaking implementation of palliative care services.

What do we really know about foundations' funding of mental health?

This paper examines mental health giving by foundations and points to a continuing downward trend in philanthropic giving to mental health, relative to overall and health giving. The authors reviewed data and interviewed staff from foundations that accounted for the majority of mental health funding in 2006. Using this quantitative and qualitative information, the authors identify important unanswered questions about foundation funding for mental health and suggest that the lack of precision in how mental health funding is defined and measured is symptomatic of the mental health field in general and may contribute to grantmakers' low level of attention to it.

Addressing homelessness among people with mental illnesses: a model of long-term philanthropic effectiveness.

Foundations are often criticized for their short attention spans and inability to continue funding the toughest social problems. Homelessness among people with mental illnesses is considered among the most intractable of social issues. This paper explores the role of permanent supportive housing in reducing homelessness among the mentally ill; the role of the Corporation for Supportive Housing in developing, authenticating, and disseminating its model; and its long-term funding relationship with the Conrad N. Hilton Foundation, which has facilitated this trajectory. The paper tells the story of how long-term funding, strategically used, is making inroads into this serious mental health problem.

Strengthening a state's health advocacy infrastructure.

Although coordination among advocates may be a critical ingredient for achieving health policy change, opportunities for discussions that lead to cooperation among advocates are rare. For the past seven years, the California Wellness Foundation has funded an annual two-day retreat for California health advocates. These gatherings have created a reflective time period for them to consider their differing advocacy agendas as well as areas of overlap. The retreats have also helped to soften the fault lines that can be barriers to cooperation. An independent evaluation has provided some important points for foundations to consider when making grants for such a retreat.

Are foundations overlooking mental health?

Over the past decade philanthropic giving for health has increased dramatically, but giving for mental health has not kept pace. Historically, foundations have been key partners in efforts to improve care for people with mental disorders, and foundation funding has influenced the evolution of U.S. mental health services and systems. Although mental health giving grew in the 1990s, the rate of growth was far below that for total foundation giving or giving for health. The authors suggest possible reasons why mental health funding lost ground and describe promising funding approaches and models for increasing both the amount and the impact of philanthropic giving for mental health.