Asking the right question.

245 THE AMERICAN HOSPITAL ASSOCIATION’S (AHA) Circle of Life Award reflects the increasing awareness of a need to afford each of us an opportunity to discuss, plan, and define the kind of care we want as we approach death. The recognition of Franciscan Health System West’s Improving Care Through the End of Life is noteworthy because this program possesses key elements required to build systems of care that are reliably responsive to our needs and wishes when we become seriously ill and approach the end of life. It is important to understand the program’s key features as well as the context of health care in the new millennium. Health professionals, insurance companies, and care systems continue to focus on episodic and acute interventions. Much of this care is breathtaking. Most people want state of the art care that will truly benefit them, but also want more than what technology alone can offer them. They desire personalized, responsive care that is respectful of their concerns, fears, culture, and values. Moving from concept to change in clinical practice is often difficult. Mixed incentives, shifting reimbursement methodologies, realignments among traditional allies, and declining revenue make change especially challenging as payers and regulators require physicians and other health professionals to do more in less time.1 Innovation in the current environment is difficult if it cannot fulfill the mandate to have a clear and immediate “return on investment.” Any new program that does not have a rapid and obvious payback faces very considerable barriers. Promising innovations in areas where there is strong professional or cultural resistance face even greater obstacles. Improving Care Through the End of Life is an example of how a small group of individuals successfully met these challenges and made a difference. The actual moment of death is brief, but most of us will spend months to years in predictable steady decline. This period is punctuated by losses, but it can be a time for growth, development and closure. Few today would disagree that we each should have the opportunity to know our diagnosis and prognosis, decide what treatments we want, complete unfinished business, express where we want to die, and appoint someone who will make health care decisions for us when we no longer want to or cannot participate in making them. The Franciscan program provides its participants with the opportunity to accomplish these tasks. Many provider groups are developing population management programs. Population management is based on the understanding that the traditional delivery system does not do a particularly good job at identifying and managing people at high risk from particular diseases or conditions. Health care insurers, systems and providers are investing considerable resources in this approach because individuals with diabetes, congestive heart failure, renal failure and other conditions are typically high cost. Population management relies on evidence-based medicine and introduces additional elements into the traditional approach to care. It usually has elements that ensure better continuity. Significantly less attention and fewer resources have been devoted to developing population management programs that do not have an immediate return on investment and on conditions that do not have an obvious medical responsibility.2 Programs for frail older adults, people with dementia, or those approaching the end of life fall into this category. Why then has the Franciscan program met with