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Article
Article
In the early days of the COVID-19 pandemic, the leadership team at Shaw Cancer Center in Edwards, Colorado, identified an alarming trend. A growing number of patients with cancer were stranded in limbo while waiting for home care and hospice services that never materialized. More than 30 patients remained on a waitlist, and nearly two-thirds of those referred for support experienced significant delays or were declined services entirely.
For patients in the mountain towns surrounding Vail, distance, weather, and limited health care infrastructure compounded the challenge. Patients were receiving world-class treatment at our cancer center, but when they went home, they often had no one to help them manage difficult symptoms or navigate the end of life. The team at Shaw Cancer Center knew it could do better.
That recognition became the spark for Shaw at Home, an oncology-specific home- and community-based palliative care program that has redefined what continuity of care can look like in a rural mountain community.
From Idea to Implementation
The concept for Shaw at Home took shape in June 2020 when COVID-19 disrupted traditional care models. Over the next 3 years, a small but determined group of clinicians, social workers, and community advocates worked to design a new type of support for patients who could not safely or reliably access home services. Between July 2020 and May 2023, the team developed the program step by step, projecting patient volumes, securing licensing through the Colorado Department of Public Health and Environment, designing staffing models, and laying out groundwork for long-term sustainability. The first patient was seen on June 1, 2023, marking the beginning of a new chapter for Shaw Cancer Center, one that brings essential care and guidance directly into patients’ homes.
Why It Works: A Culture of Innovation and Compassion
With a long-standing culture that emphasized innovation, wellness, and whole-person care, Shaw Cancer Center was uniquely positioned to launch a program such as Shaw at Home. For nearly 2 decades, Shaw has created programs that reach beyond traditional cancer treatment, including the following:
Shaw’s DNA is about meeting people where they are. Bringing this kind of in-home support for people with serious illness was simply the next logical step.
Collaboration as a Cornerstone
From the outset, the team sought mentorship and partnership from leading programs across the country, including Huntsman at Home, University of Colorado Health’s Palliative Care Program, and experts from the Center to Advance Palliative Care (CAPC), such as Regina Fink, PhD, RN; and Nancy Robertson, DNP, NP, ACHPN. These collaborations helped Shaw Cancer Center adapt proven models to the unique geographic and demographic realities of the Colorado mountains. The resulting program integrates smoothly with Shaw’s cancer services and provides in-home support that includes medical symptom management, guidance for difficult decisions, emotional support, and help with planning for future care. All services are delivered where patients feel safe: at home.
Building the Team
The success of Shaw at Home rests on an interdisciplinary team committed to holistic, patient-centered care. The core team includes:
The team works under a shared approach that is grounded in relationships, trust, and a commitment to meeting patients where they are. As nurse practitioner Shelly Schwartz explains, “I wanted to join Shaw at Home because I want our patients to have access to care from people they know and trust, to help them understand their illness, and to make choices that honor what matters most.”
Organizations interested in offering (and billing for) these services must choose between licensing as a home health agency (“Class A”)—allowing for skilled care reimbursed under Medicare Part A—or as an organization—covered under Medicare Hospice benefits—based on their intended scope and regulatory requirements. Shaw opted for the broader Class A home health agency license, which permits both palliative-type services and other skilled-care services.
Shaw at Home Staffing Model
The Shaw at Home program is built on a flexible, interdisciplinary staffing structure designed to deliver seamless care across clinic, home, and telehealth settings. The team includes 2 APPs—one funded through Shaw at Home and one through medical oncology—who rotate monthly between departments. Both APPs work in clinic on Mondays, with one transitioning Tuesday through Thursday to provide home-based, telehealth, or hospital visits, often traveling alongside other team members to meet patients wherever they are. Nursing support consists of 1.6 FTE RNs who split three 10-hour shifts each week, overlapping on Wednesdays to ensure continuity and handoff. Additional core roles include a full-time referral and scheduling specialist, 2.8 FTE licensed clinical social workers, and 2.0 FTE chaplains, all of whom provide Monday–Friday coverage for emotional and spiritual support. This structure allows Shaw at Home to remain nimble: while staffing ratios are largely fixed, the team adapts to fluctuating caseloads by calling in additional help when needed. Although patient volumes vary, the program has learned that 4 to 6 home visits per day is typically the maximum, with capacity increasing when clinic and telehealth visits are combined. By blending dedicated roles with cross-functional flexibility, Shaw at Home ensures patients receive comprehensive, compassionate care wherever they need it most.
Scheduling and Triage for Home Visits
Shaw at Home relies on a streamlined scheduling and triage process to ensure patients receive timely, appropriate care. A full-time referral and scheduling specialist coordinates all visits, serving as the central hub for communication and logistics. Business hours run from 7:30 am to 6:30 pm, with after-hours and weekend coverage managed through a rotating on-call system. APPs alternate monthly for after-hours and weekend call, while 2 RNs share weekend on-call responsibilities to support urgent needs. Urgent visits typically involve pain crises or significant health declines, particularly for patients nearing end of life or transitioning home from hospitalization. Routine visits, by contrast, are scheduled based on follow-up intervals determined by the APP during prior encounters. This triage approach ensures that urgent needs are prioritized while maintaining continuity for ongoing care.
Structure of a Home Visit
Most Shaw at Home visits are interdisciplinary, with roughly 65%–70% involving multiple team members. APPs lead medical symptom management, supported by RNs who screen and report findings as needed. Psychosocial and spiritual care are seamlessly integrated, with social workers and chaplains often co-leading conversations alongside medical providers to create space for emotional and spiritual processing. Every initial visit includes social work and spiritual care, and these disciplines remain involved unless a patient specifically declines—an uncommon occurrence given their high value to patients and families. While single-discipline visits do occur, Shaw at Home emphasizes team-based care whenever possible, recognizing the profound impact of a united approach on patient experience and outcomes.
Growing the Program
As of December 31, 2025, Shaw at Home has provided 2154 total palliative care visits within the home (community) and clinic (Table 1). These visits have centered around goals of care discussions, advance care planning, transitions of care, symptom management, and psychological and spiritual exploration and support. Shaw at Home has provided these services to 180 unique patients. The program has allowed patients to experience a continuous transition of care between hospital and home, as well as continuity of care through end-of-life as Shaw at Home provides wrap-around care to compliment and support hospice efforts in its rural community.
Philanthropy and Sustainability
The growth of Shaw at Home has been fueled by strong philanthropic support, led by the Vail Health Foundation. An early $1 million gift from a single donor provided the resources needed to launch the program and operate it during its first 3 years. From the beginning, the team built a financial model that could sustain the program long after its start-up phase. About one-third of its ongoing support comes from philanthropy, while the remaining two-thirds are generated through program revenue, including billable visits. This balanced approach allows Shaw at Home to reach patients who need care, regardless of their insurance coverage or ability to pay.
Patient-Centered Results
Two and a half years after program launch, Shaw at Home has received remarkable feedback in patient satisfaction surveys. Specifically, on a scale of 1 to 10, 97% of patients rated the care they received at Shaw at Home as 10. Anecdotally, many patients have shared that the program has helped them feel more in control of their care, better understood, and less anxious. One patient said, “Having my care team come to me changed everything. I could finally focus on being comfortable, not on logistics.” Clinicians have noted benefits such as better symptom management, fewer emergency department visits, and smoother transitions to hospice when it became the right choice.
Keys to Success
Looking back on the journey, the Shaw team points to several lessons that other cancer programs, particularly those in rural or resource-limited areas, can learn from:
Ripple Effects in the Community
Beyond direct patient impact, Shaw at Home has strengthened the region’s entire continuum of cancer care. Local hospice providers now collaborate more closely with Shaw Cancer Center clinicians, and primary care teams receive support on symptom management and conversations about goals of care.
Shaw at Home has changed how the community thinks about serious illness, making palliative care visible, accessible, and deeply personal.
Shaw at Home is also emerging as a model for other rural communities. Cancer centers across the country that face similar challenges of geography and workforce scarcity can adapt the program’s approach by integrating home-based support into existing oncology services, using telehealth more effectively, and building strong community partnerships.
Looking Ahead
The Shaw at Home team continues to refine and expand the program. Future goals include the following:
The goal: to ensure that compassionate, coordinated, home-centered care is available to all patients, no matter where they live.
A Model Rooted in Community
In a health care landscape where innovation often means new technology or artificial intelligence, Shaw at Home stands out for something simpler and more human: bringing care to the place where life happens. For the Shaw at Home team, it is not just a program. It is a philosophy that honors the mountain community’s spirit of resilience, connection, and compassion. Ultimately, this model of care could reshape the future of rural oncology care, bringing comfort and dignity to patients, one home at a time.
Patricia Hardenbergh, MD, FASTRO, is medical director, and Erin Perejda, MSW, LCSW, OSW-C, is supportive care services manager at Shaw Cancer Center, Vail Health, in Edwards, Colorado.
