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Home Support for Palliative Patients

Best Practices

Created on December 05, 2017

“Insanity is doing things the way we’ve always done them and expecting different results.”
Albert Einstein

Home Support for Discharged Palliative Patients is a priority indicator for the Quality Improvement Plans (QIPs). This indicator measures the percentage of palliative patients discharged home from hospital with the discharge status “Home with Support”.

Below are best practices for managing and improving this indicator. They are graded according to Type of Evidence. Evidence-informed best practices are based on high-quality evidence; they can optimize outcomes and should be implemented into practice where possible.

To help you move from best evidence to best practice, you can refer to the one of the following resources:

Or browse the interactive table below for some key change ideas on how to improve home support for discharged palliative patients.

  1. Benzar E., Hansen L., Kneitel A. W., Fromme E. (2011).
    Discharge Planning for Palliative Care Patients: A Qualitative Analysis.
    Journal of Palliative Medicine; 14 (1): 65 – 69.

  2. Brazil K; Whelan T; O'Brien MA; Sussman J; Pyette N; Bainbridge D.(2004).
    Towards improving the co-ordination of supportive cancer care services in the community.
    Health Policy. 70(1):125-131.

  3. Brink P; Partanen L. (2011).
    Emergency department use among end-of-life home care clients.
    Journal of Palliative Care. 27(3):224-228.

  4. Brink P; Frise Smith T. (2008).
    Determinants of home death in palliative home care: using the interRAI palliative care to assess end-of-life care.
    American Journal of Hospice & Palliative Medicine. 25(4):263-270.

  5. Chai H; Guerriere DN; Zagorski B; Coyte PC. (2014).
    The magnitude, share and determinants of unpaid care costs for home-based palliative care service provision in Toronto, Canada.
    Health & Social Care in the Community. 22(1):30-39.

  6. Fullerton SL; Kenner DJ; Tucker MT. (2012).
    "Anywhere to palliative care" - a fast-track pathway from the emergency department to palliative care.
    Medical Journal of Australia. 196(9):566.

  7. Howarth G; Willison KB. (1995).
    Preventing crises in palliative care in the home.
    Role of family physicians and nurses [Review]. Canadian Family Physician. 41:439-445.

  8. Klinger CA; Howell D; Marshall D; Zakus D; Brazil K; Deber RB. (2013).
    Resource utilization and cost analyses of home-based palliative care service provision: the Niagara West End-of-Life Shared-Care Project.
    Comment in: Palliat Med. 2013 Feb;27(2):103-104.

  9. Luckett T; Phillips J; Agar M; Virdun C; Green A; Davidson PM. (2014).
    Elements of effective palliative care models: a rapid review. [Review].
    BMC Health Services Research. 14:136.

  10. Masella C; Garavaglia G; Borghi G; Castelli A; Radaelli G; Peruselli C. (2015).
    Implementation of a Hospital-Based Home Palliative Care at regional level: a quantitative study of the Ospedalizzazione Domiciliare Cure Palliative Oncologiche program in Lombardy.
    Palliative Medicine. 29(3):241- 248.

  11. Moback, Berit; Gerrard, Ruth; Minton, Ollie; Campbell, Janet; Taylor, Lucie; Stone, Patrick Charles. (2011).
    Evaluating a fast-track discharge service for patients wishing to die at home.
    International Journal of Palliative Nursing. 17(10):501-506.

  12. Montero AJ; Stevenson J; Guthrie AE; Best C; Goodman LM; Shrotriya S; Azzouqa AG; Parala A; Lagman R; Bolwell BJ; Kalaycio ME; Khorana AA. (2016).
    Reducing Unplanned Medical Oncology Readmissions by Improving Outpatient Care Transitions: A Process Improvement Project at the Cleveland Clinic.
    Journal of oncology practice/American Society of Clinical Oncology. 12(5):e594-602.

  13. Morrison J; Palumbo MV; Rambur B. (2016).
    Reducing Preventable Hospitalizations with Two Models of Transitional Care.
    Journal of Nursing Scholarship. 48(3):322- 329.

  14. Plummer S; Hearnshaw C. (2006).
    Reviewing a new model for delivering short-term specialist palliative care at home.
    International Journal of Palliative Nursing. 12(4):183-188.

  15. Pouliot K; Weisse CS; Pratt DS; DiSorbo P.(2017).
    First-Year Analysis of a New, Home-Based Palliative Care Program Offered Jointly by a Community Hospital and Local Visiting Nurse Service.
    American Journal of Hospice & Palliative Medicine. 34(2):166-172.

  16. Poulose JV; Do YK; Neo PS. (2013).
    Association between referral-to-death interval and location of death of patients referred to a hospital-based specialist palliative care service.
    Journal of Pain & Symptom Management. 46(2):173-181.

  17. Reyes-Ortiz CA; Williams C; Westphal C. (2015).
    Comparison of Early Versus Late Palliative Care Consultation in End-of-Life Care for the Hospitalized Frail Elderly Patients.
    American Journal of Hospice & Palliative Medicine. 32(5):516-520.

  18. Seow H; Dhaliwal G; Fassbender K; Rangrej J; Brazil K; Fainsinger R. (2016).
    The Effect of Community-Based Specialist Palliative Care Teams on Place of Care.
    Journal of Palliative Medicine. 19(1): 16-21.

  19. Sussman J., Barbera L., Bainbridge D., Howell D., Yang J., Husain A., Librach S.L., Viola R., Walker H. (2011).
    Health system characteristics of quality care delivery: A comparative case study examination of palliative care for cancer patients in four regions in Ontario, Canada.
    Palliative Medicine; 26 (4): 322 – 335.

  20. Shaw J; Kearney C; Glenns B; McKay S. (2016).
    Interprofessional team building in the palliative home care setting: Use of a conceptual framework to inform a pilot evaluation.
    Journal of Interprofessional Care. 30(2):262-264.

  21. Tan WS; Lee A; Yang SY; Chan S; Wu HY; Ng CW; Heng B.H. (2016).
    Integrating palliative care across settings: A retrospective cohort study of a hospice home care programme for cancer patients.
    Palliative Medicine. 30(7):634-41.

  22. Venkatasalu MR; Clarke A; Atkinson J. (2015).
    'Being a conduit' between hospital and home: stakeholders' views and perceptions of a nurse-led Palliative Care Discharge Facilitator Service in an acute hospital setting.
    Journal of Clinical Nursing. 24(11-12):1676-1685.

  23. Wilkins KL; D'Agostino N; Penney AM; Barr RD; Nathan PC. (2014).
    Supporting adolescents and young adults with cancer through transitions: position statement from the Canadian Task Force on Adolescents and Young Adults with cancer. [Review].
    Journal of Pediatric Hematology/Oncology. 36(7):545-551.

  24. Yu, Mo; Guerriere, Denise N; Coyte, Peter C. (2015).
    Societal costs of home and hospital end-of-life care for palliative care patients in Ontario, Canada.
    Health & Social Care in the Community. 23(6):605-618.

Measurement

Created on December 05, 2017

“While all changes do not lead to improvement, all improvement requires change”
Institute for Healthcare Improvement

How do we know if a change is an improvement? Measurement is a critical step in QI to assess the impact of a change. Quality indicators are used in the QIPs to measure how well something is performing. There are three types of quality indicators used to measure QI efforts:

  • Outcome Indicators: capture clinical outcomes and or system performance,
  • Process Indicators: track the processes that measure whether the system is working as planned, and
  • Balancing Indicators: ensure that changing one part of the system does not cause new problems in another.

Indicator

Home Support for Discharged Palliative Patients

Topic Access, End-of-Life/Palliative
Quality Dimension Patient Centred
Type of Indicator Outcome
Measure Rate per total number of discharged patients
Data Source

Discharge Abstract Database (DAD) from CIHI

Data Collection Instrument Provided to HQO by Cancer Care Ontario (CCO)
How to Calculate

The percentage is calculated as: (Numerator/Denominator) x 100

Numerator: # of inpatient acute care discharges who are discharged "home with support".

Denominator: # of home discharges in the reporting period with a hospital admission which indicates that the patient is receiving palliative care.

Target Higher is better (Increase)
Range 0 – 100%
HQO Reporting Tool Quality Improvement Plans (QIPs)

This data can be presented using Run Charts to track improvement over time. To read more about general measurement in QI refer to Measurement for Quality Improvement or the QI Getting Started Section.

Tools & Resources

Created on December 05, 2017

Health Quality Ontario’s Tools and Resources
Other Tools and Resources

Background

Created on December 05, 2017

Issue

We know patients should receive palliative care much earlier than they often do, with a multidisciplinary team and a smooth transition from acute care in the hospital to home (HQO 2016). This increases the patient’s ability to die in their preferred place, with the supports they need. In the past, the approach to palliative care was that it wouldn’t begin until the very latest stages of the illness or often not at all. The newer approach to palliative care is that it can begin immediately after the patient is diagnosed with a life-limiting condition. Efforts to improve palliative care delivery will require engaging with the public, with clinicians and teaching people to understand the role of palliative care and the supports required when they are discharged from the hospital (HQO, 2017).


Call to Action

Discharge planning is an important part of hospital-based palliative care consultations. A palliative care consultation provides patients, families and caregivers with the information and support they will need upon exiting the hospital and transitioning into the community (Benzar et al. 2011). If this palliative consultation does not appropriately prepare and equip the patient to be discharged into the community and the appropriate linkages and supports are not readily available once the patient is discharge home a subsequent readmission to the emergency department, to acute may result. This will take the patient away from the home environment they prefer to be in, and force them to proceed through the acute care loop once more. Discharging patients home with support is important for avoiding this and there are system factors that can be identified that are associated with population palliative care outcomes (Sussaman et al. 2011).

  1. Benzar E., Hansen L., Kneitel A. W., Fromme E. (2011).
    Discharge Planning for Palliative Care Patients: A Qualitative Analysis.
    Journal of Palliative Medicine; 14 (1): 65 – 69.

  2. Health Quality Ontario. Palliative Care Quality Standard (DRAFT).
    Queens Printer for Ontario, 2017. Toronto ON.
    Retrieved from: http://www.hqontario.ca/Evidence-to-Improve-Care/Quality-Standards/View-all-Quality-Standards/Palliative-Care

  3. Health Quality Ontario.
    Palliative Care at the End of Life.
    Queens Printer for Ontario, 2016. Toronto ON.
    Retrieved from: http://www.hqontario.ca/System-Performance/Specialized-Reports/Palliative-Care-Report

  4. Hospice Palliative Care Association.
    Cost-effectiveness of palliative care: A review of the literature.
    The Way Forward Initiative: an Integrated Palliative Approach to Care; 2012.
    Retrieved from: http://www.hpcintegration.ca/media/36290/TWF-Economics-report-Eng-finalwebmar7.pdf

  5. Sussman J., Barbera L., Bainbridge D., Howell D., Yang J., Husain A., Librach S.L., Viola R., Walker H. (2011).
    Health system characteristics of quality care delivery: A comparative case study examination of palliative care for cancer patients in four regions in Ontario, Canada.
    Palliative Medicine; 26 (4): 322 – 335.