conducting end-of-life discussions is presented. The four steps are based on structured interviews at a major university hospital with five faculty clinicians experienced in the care of dying patients. Their experiences and actual words have been synthesized into this 4-step approach. The four steps are: 1) Initiating Discussions 2) Clarifying Prognosis 3) Identifying End-of-Life Goals 4) Developing a Treatment Plan FINDINGS TO DATE: Using the 4-step approach with your patients will result in improved communication. Good communication results in patient fears being allayed, pain and suffering minimized, and facilitates developing a treatment plan that is medically sound and concordant with the patient's wishes and values. KEY LESSONS LEARNED: Providing good end-of-life care requires both an understanding of how patients and famlieis experience the dying process, and a sensitive communication style. With these skills, physicians are able to conduct thoughtful discussions in which most decisions evolve comfortably and without controvery. Providing care for a dying patient is challenging, and when done well, is a meaningful and gratifying experience for the physician. To help someone die in comfort, in peace, and with dignity is to give one final gift of life. and an audience response system was also used to administer the questionnaire during a noon conference FINDINGS TO DATE: Thirty five HS participated in this survey; (48% GL-I, 24% GL-II, 14% GL-III, 7% GL-V). Most of them thought the book was trustworthy (87%), accurate (86%), user friendly (57%), and overall useful for the management of patients (87%). Although most HS always carried the CCF book (73%), most also carried other commercially available antibiotics recommendations book(s) (68%). There was no consensus which of these books was more useful for them. The CCF Book sections on guidelines for specific diseases and dosing information were referred to most often (37% & 40%; respectively). Requests were made to add more microbiology information and other clinically important antimicrobial drug interactions. KEY LESSONS LEARNED: The CCF Guidelines for Antimicrobial Usage book is well respected among the HS. The book serves it's purpose well in helping HS with their daily care of hospitalized patients. This survey helped us in implementing some changes that we believe will improve these guidelines and consequently, improve the quality of care for our patients. On an average there are close to 1,500 patients seen in this unit annually, with a wide variety of medical, surgical and rehabilitation problems requiring skills of a physician trained in the care of these patients. This presentation is based on our experience and observation. The Lecture format will be as follows: Introduction: Advances in technology and an increase in life expectancy for the general population have resulted in an increasing demand for medical services. In the early 1980s, for example, Medicare introduced the Diagnosis Related Group (DRG ) based system of payment for inpatient care. The DRG system created financial disincentives for the hospitals by imposing a fixed reimbursement rate for each condition unrelated to patient acuity or the actual costs of care incurred by the hospital. In response, many hospital systems created alternative discharge sites, thus shifting care to subacute units, nursing homes, and home-based care. Principles of subacute care The philosophy of Subacute or Transitional care units is the management of patients after acute exacerbation of an illness, providing a more healing environment and a change of focus away from high technologic interventions. While these patients do not need intense diagnostic work-up or invasive procedures, they still require frequent physician monitoring, nursing care, and rehabilitation. Patient Selection: The decision of appropriate referral to subacute unit is a key to both continuity of care and financial viability. Appropriate subacute care candidates must have a definitive goal and identified skilled needs. It is important to identify these patients as early as possible during their acute hospitalization in order to reduce the length of stay. Examples of patients appropriate for subacute units will be discussed in detail. Also difference between these patients and nursing home patients requiring custodial care will be discussed. Financial challenges: As the number and type of alternate care sites have increased, federal efforts at cost containment have shifted to limit financial reimbursement to post-acute care facilities as well. The Balance Budget Act of 1997 introduced the Prospective Payment System for these units, shifting the reimbursement from per-diem rate to a fixed rate which would include all the ancillary services received by a patient except physician visits. This fixed rate is calculated based on the Resource Utilization Group per Medicare guidelines. In many cases, the cost of providing care for medically complex patients far exceeds the reimbursement. Mounting economic pressure to contain treatment costs may threaten the financial health of many subacute units especially as hospitals seek to admit only the sickest of the sick and treat them in the shortest possible amount of time. This section will include discussion on the problems created by these changes in reimbursement and the possible solution to maintain quality of care. Educational opportunities: With the decrease in length of stay on the acute inpatient site and increasing medical complexity, subacute units continue to provide care for a variety of patients. Members involved in their care require both medical and surgical skills. Our subacute unit is a site for residency training program and continues to offer wide variety of experience ranging from routine postoperative care to caring for the elderly and medically sick patients. Residents also learn the importance of maintaining functional integrity in elderly patients, concepts of rehabilitation working in an interdisciplinary team model and dealing with end of life decisions. They also learn to provide care in face of financial cut-backs, without compromising on the quality of care. Outcomes research continues to remain an unexplored area in this arm of health care. The value of this cannot be underestimated, especially in view of financial cut-backs, with the goal of maintaining a high standard of care for an enlarging, vulnerable patient population in this new environment. FINDINGS TO DATE: KEY LESSONS LEARNED: