Promoting Excellence : Rural Private Practice

Palliative Care Concepts, Inc.
Greenville, Ohio

Michelle A. Hobbs, RN, MS, CNP

Michelle A. Hobbs Michelle Hobbs, a family nurse practitioner, is president of Palliative Care Concepts, Inc., an independent practice headquartered in Greenville, Ohio, the county seat of rural Drake County (population: 53,309). In Ohio, nurse practitioners can provide comprehensive health assessments, diagnose and manage acute and chronic illnesses, order and interpret diagnostic studies, and formulate care plans to manage illness and promote wellness.

In her practice, Hobbs provides pain and symptom management, assists with advanced care planning, assesses emotional needs, offers psychosocial and spiritual support, and identifies and accesses community resources. She has prescriptive authority through a pilot project at Wright State University in Dayton, Ohio, and is required to practice within a collaborative agreement established with one or more physicians. “I’ve focused my practice on palliative care for patients of all ages and in all settings,” explains Hobbs, who sees her patients wherever they are—at home, in a nursing home, in the hospital or in an assisted-living facility.

Hobbs is the only nurse practitioner on the medical staff at Wayne Hospital in Greenville, Ohio. Patients are referred to her by physicians, who consider her services an extension of the care they provide, or by nurses and social workers in hospitals and nursing homes. Patients also call her directly after hearing about her services from a friend or reading about her in the local newspaper.

Overcoming the Challenges
Hobbs overcame some major hurdles when she started her practice two years ago. “I was one of the first nurse practitioners in this county and the very first to start an independent practice,” she explains. “Many people were unfamiliar with nurse practitioners, and palliative care was not well understood.”

With the support of local physicians, Hobbs began to provide an additional service—a wellness program that helps patients newly diagnosed with chronic, potentially terminal illnesses stay as well as possible while living with progressive disease. Patients and caregivers in this program are educated about their specific disease condition, medications and plan of care. Patients also participate in advanced care planning to ensure that their wishes are always honored. In addition, Hobbs introduces patients and families to community resources that can assist with practical needs. She also conducts a Care for the Caregiver class, in which she teaches how to care for an ill loved one and offers practical advice to caregivers in dealing with their own psychosocial and spiritual concerns.

The majority of Hobbs’s patients reside in nursing homes. She has provided consultation in six area nursing homes to ensure that patients receive adequate pain and symptom management. She is now working with these nursing homes to implement a demonstration project designed to build palliative care teams and change policies and procedures to provide a full range of palliative care services.

Paying for Practice
After two years, Hobbs’s practice is self-supporting, sustained by reimbursements and fee-for-service revenues, and is not underwritten by any medical institution. She has her own Medicare and Medicaid provider numbers and bills patients or their third-party payers directly for consults and care. Some HMOs do not reimburse any nurse practitioner services, however Hobbs has found this exclusion to be rare.

Extending a Successful Approach Through Education and Service
Hobbs believes that nearly 100 percent of her patients experience some improvement in their symptoms. “My patients and families feel more in control in a very out-of-control situation,” she says. “In the past, patients have had to choose between aggressive curative treatment or comfort-oriented care. Palliative care brings those two ends of the spectrum together, allowing patients to be comfortable from the time they are diagnosed with a potentially terminal illness through the moment of their death.”

Hobbs, who chairs the pain committee at Wayne Hospital, has presented many pain education seminars. She is also a member of the faculty at Wright State University, where she is exploring ways to weave palliative care into undergraduate and graduate nursing curricula. Hobbs has conducted research examining pain assessment and treatment in cognitively impaired elderly and has given a number of seminars in Ohio on this topic. She has also presented a teleconference for the Hospice and Palliative Nurses Association and serves as an expert on the association’s “Ask the Expert” Web page.

She believes the Wayne Hospital model is ideal for implementation in rural communities where no one health care organization or facility can support a full palliative care program. Palliative care services led by a nurse practitioner can be woven throughout the existing health care structure of a small community.

Personal Reflection
Hobbs advises nurses exploring APN practice of palliative care to “know you can make a huge difference in people’s lives. APNs have a significant body of knowledge, experience and expertise. Our autonomy allows us to care for patients and families in truly innovative ways and fill gaps in the current health care system.”

Promoting Excellence in End-of-Life Care was a national program of the Robert Wood Johnson Foundation dedicated to long-term changes in health care institutions to substantially improve care for dying persons and their families. Visit for more resources.

Promoting Excellence logo and link to home page