A s America ages and life spans increase in an era of medical miracles, the need for end-of-life care will grow proportionately. Demand for hospice services has risen even as our society debates its approach to death and the process of dying. It is not surprising, then, that the concept of palliative care is receiving greater recognition and acceptance from medical professionals, the patients who receive lifeprolonging treatments, and their families.The increasing demand for palliative care offers significant opportunity for hospice organizations to build hospice census, operating profits, hospital partnerships, and awareness about end-of-life care. Although there is no designated reimbursement for palliative care, growth in palliative care will affect growth in hospice average daily census and, hence, revenues to the program. When the average daily census for a hospice provider reaches breakeven, operating profits can reach the 10% percent range and rise with a growing census, according to a report by investment banking firm Shattuck Hammond Partners LLC (2004). While the focus of such reports has been on for-profit publicly traded hospices, some nonprofit providers are beginning to achieve similar results with a focus on quality patient care delivery and innovative end-of-life care programs. In addition, innovative providers have accessed reimbursement to cover palliative care services from Medicare Part B and private insurance companies.

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Every community is or will be faced with the challenge of caring for individuals with acquired immunodeficiency syndrome (AIDS) and AIDS-related complex (ARC). In most communities in the United States, home health care is an existing alternative to hospitalization. Although there are many potential barriers to home health and hospice care provision, these barriers are not insurmountable. As demonstrated by the community's response in San Francisco, careful planning, cooperation, and education reduce the barriers to allow persons with AIDS/ARC to receive care at home or to identify alternatives when home care is no longer an option. The AIDS Home Care and Hospice Program of the Visiting Nurses and Hospice of San Francisco is used as the model for the article. This program was the first of its kind in the world. It has developed an innovative approach to home and hospice care for persons with AIDS/ARC. Its sensitive and humane approach, offers support from early in the disease process (to assist patients as they struggle with difficult treatment decisions) until long after death occurs (to enable friends and family members to cope with the loss of a loved one). This article identifies the challenges that administrators and staff face in keeping the terminally ill individual with AIDS/ARC at home, offers suggestions to best meet the needs of the person with AIDS/ARC living at home, and suggests alternatives when home care is no longer an option.

By early 1986, over 16,000 people had been diagnosed with AIDS in the United States. It has been estimated that between 5 percent and 15 percent of these are hospitalized at any given time. Of the 80 to 95 percent who are living at home, some are experiencing few symptoms and independent in their activities of daily living. However, approximately 20 to 25 percent of those living at home experience chronicor acute symptoms associated with AIDS, requiring intervention by the home team. Home care agencies throughout the country have provided services to people with AIDS in the home utilizing basic, standard precautions for infection control.This article will provide information regarding disease transmission, both to allay the anxieties of home care personnel concerned about working with AIDS patients, and to enable them to utilize appropriate precautions to prevent the transmission of AIDS and the associated opportunistic infections.