Palliative care transitions from acute care to community-based care: A qualitative systematic review of the experiences and perspectives of health care providers

Organisation and management of multi-professional care for cancer patients at end-of-life: state-of-the-art from a survey to community and hospital-based professionals

Providing timely and satisficing End-of-Life care (EOLC) is a priority for healthcare systems since aging population and chronic diseases are boosting the global demand for care at end-of-life (EOL). In OECD countries the access to EOLC is insufficient. In Italy, the average rate of cancer patients assisted by the palliative care (PC) network at EOL was 28% in 2021, with high variability in the country. Among the Italian regions offering the best coverages, Tuscany has a rate of about 40%, but intraregional variation is marked as well. The study aims to explore the delivery of EOLC to adult cancer patients in public facilities in the Tuscany region through survey data collection among professionals. Two online surveys were delivered to Directors of community-based PC Functional-Units (FUs) and Directors of hospital-based medical-oncology units. All FU Directors responded to the survey (n = 14), and a response rate of 96% was achieved from hospital-unit Directors (n = 27). The results highlight the availability of numerous dedicated services, but reveal heterogeneity among and within organisations, including variations in the professionals involved, pathways, and tools adopted. Care continuity is supported by institutionalized collaboration between hospital and community settings, but hindered by fragmented care processes and heterogeneous transition pathways. Late referral to PC is perceived as a major constraint to EOLC. Developing structured pathways for patient transition to end-stage PC is crucial, and practices/processes should be uniformly implemented to ensure equity. Multi-professional care should be facilitated through tailored supporting tools. Both hospital-unit and FU Directors suggest developing shared pathways between organisations/professionals (82% and 80% respectively) and digital information sharing (61% and 80% respectively). Hospital and community-based professionals have similar perceptions about the concerns and challenges to EOLC provision in the region, but community-based professionals are more sensitive to the importance of improving communication on PC to the public and early discussing EOLC with caregivers. This finding suggests the need of enhancing hospital personnel's awareness about these issues. Professional training and the capacity to assess patients' needs and preferences should be improved. The identified needs can inform future research and interventions to improve the quality and outcomes of EOLC for cancer patients.

Put on the sidelines of palliative care: a qualitative study of important barriers to GPs' participation in palliative care and guideline implementation in Norway

BACKGROUND

Demographic changes, the evolvement of modern medicine and new treatments for severe diseases, increase the need for palliative care services. Palliative care includes all patients with life-limiting conditions, irrespective of diagnosis. In Norway, palliative care rests on a decentralised model where patient care can be delivered close to the patient's home, and the Norwegian guideline for palliative care describes a model of care resting on extensive collaboration. Previous research suggests that this guideline is not well implemented among general practitioners (GPs). In this study, we aim to investigate barriers to GPs' participation in palliative care and implementation of the guideline.

METHODS

We interviewed 25 GPs in four focus groups guided by a semi-structured interview guide. The interviews were recorded and transcribed verbatim. Data were analysed qualitatively with reflexive thematic analysis.

RESULTS

We identified four main themes as barriers to GPs' participation in palliative care and to implementation of the guideline: (1) different established local cultures and practices of palliative care, (2) discontinuity of the GP-patient relationship, (3) unclear clinical handover and information gaps and (4) a mismatch between the guideline and everyday general practice.

CONCLUSION

Significant structural and individual barriers to GPs' participation in palliative care exist, which hamper the implementation of the guideline. GPs should be involved as stakeholders when guidelines involving them are created. Introduction of new professionals in primary care needs to be actively managed to avoid inappropriate collaborative practices. Continuity of the GP-patient relationship must be maintained throughout severe illness and at end-of-life.

Advancing the Care Experience for patients receiving Palliative care as they Transition from hospital to Home (ACEPATH): Codesigning an intervention to improve patient and family caregiver experiences

BACKGROUND

Returning home from the hospital for palliative-focused care is a common transition, but the process can be emotionally distressing and logistically challenging for patients and caregivers. While interventions exist to aid in the transition, none have been developed in partnership with patients and caregivers.

OBJECTIVE

To undergo the initial stages of codesign to create an intervention (Advancing the Care Experience for patients receiving Palliative care as they Transition from hospital to Home [ACEPATH]) to improve the experience of hospital-to-home transitions for adult patients receiving palliative care and their caregiver(s).

METHODS

The codesign process consisted of (1) the development of codesign workshop (CDW) materials to communicate key findings from prior research to CDW participants; (2) CDWs with patients, caregivers and healthcare providers (HCPs); and (3) low-fidelity prototype testing to review CDW outputs and develop low-fidelity prototypes of interventions. HCPs provided feedback on the viability of low-fidelity prototypes.

RESULTS

Three patients, seven caregivers and five HCPs participated in eight CDWs from July 2022 to March 2023. CDWs resulted in four intervention prototypes: a checklist, quick reference sheets, a patient/caregiver workbook and a transition navigator role. Outputs from CDWs included descriptions of interventions and measures of success. In April 2023, the four prototypes were presented in four low-fidelity prototype sessions to 20 HCPs. Participants in the low-fidelity prototype sessions provided feedback on what the interventions could look like, what problems the interventions were trying to solve and concerns about the interventions.

CONCLUSION

Insights gained from this codesign work will inform high-fidelity prototype testing and the eventual implementation and evaluation of an ACEPATH intervention that aims to improve hospital-to-home transitions for patients receiving a palliative approach to care.

PATIENT OR PUBLIC CONTRIBUTION

Patients and caregivers with lived experience attended CDWs aimed at designing an intervention to improve the transition from hospital to home. Their direct involvement aligns the intervention with patients' and caregivers' needs when transitioning from hospital to home. Furthermore, four patient/caregiver advisors were engaged throughout the project (from grant writing through to manuscript writing) to ensure all stages were patient- and caregiver-centred.

Palliative Care Providers' and Administrators' Perspectives on Integrating Community-Based Palliative Care Using the Social Determinants of Health Framework

The purpose of the study is to examine the perspectives of palliative care (PC) providers about the needs, barriers, and disparities to integrate PC into the community setting. This study used a descriptive qualitative design to complete a phone interview that incorporated the United States Department of Health and Human Services' (USDHHS) social determinants of health (SDOH) framework domains, as well as a demographic survey. Thirteen PC providers and administrators were interviewed to ascertained their perceptions about community-based palliative care (CBPC) related to the SDOH. Subthemes were ascertained using the USDHHs' SDOH as themes: lack of patient access to resources, challenges of institutional philosophic buy-in, gaps in medical education, lack of health care literacy among patients, distrust in health care, differing perspectives on quality of life, social and community support, environmental injustice, lack of interdisciplinary collaboration, multidisciplinary continuing education, and CBPC program evaluation. The results from this study provide evidence to help identify potential barriers to planning necessary CBPC interventions based on potential SDOH disparities.

Palliative Care across Settings: Perspectives from Inpatient, Primary Care, and Home Health Care Providers and Staff

BACKGROUND

Early introduction of palliative care can improve patient-centered outcomes for older adults with complex medical conditions. However, identifying the need for and introducing palliative care with patients and caregivers is often difficult. We aim to identify how and why a multi-setting approach to palliative care discussions may improve the identification of palliative care needs and how to facilitate these conversations.

METHODS

Descriptive qualitative study to inform the development and future pilot testing of a model to improve recognition of, and support for, unmet palliative care needs in home health care (HHC). Thematic analysis of semi-structured interviews with providers across inpatient (n = 11), primary care (n = 17), and HHC settings (n = 10).

RESULTS

Four key themes emerged: 1) providers across settings can identify palliative care needs using their unique perspectives of the patient's care, 2) identifying palliative care needs is challenging due to infrequent communication and lack of shared information between providers, 3) importance of identifying a clinical lead of patient care who will direct palliative care discussions (primary care provider), and 4) importance of identifying a care coordination lead (HHC) to bridge communication among multi-setting providers. These themes highlight a multi-setting approach that would improve the frequency and quality of palliative care discussions.

CONCLUSIONS

A lack of structured communication across settings is a major barrier to introducing and providing palliative care. A novel model that improves communication and coordination of palliative care across HHC, inpatient and primary care providers may facilitate identifying and addressing palliative care needs in medically complex older adults.

The 2023-2026 Hospice and Palliative Nurses Association Research Agenda

The Hospice and Palliative Nursing Association established the triannual research agenda to ( a ) provide focus for researchers to conduct meaningful scientific and quality improvement initiatives and inform evidence-based practice, ( b ) guide organizational funding, and ( c ) illustrate to other stakeholders the importance of nursing research foci. HPNA Research Agendas are developed to give direction for future research to continue advancing expert care in serious illness and ensure equitable delivery of hospice and palliative care.

Integrating Palliative Care into Nursing Care

ABSTRACT

The need for palliative care in our health care system has exponentially increased in the past few years as a result of the COVID-19 pandemic, the aging population, and the increasing number of people living with serious illnesses. While nurses play a critical role in delivering palliative care, many lack confidence and knowledge, causing practice gaps in the clinical and psychological management of seriously ill patients. The collective burden of the pandemic has demonstrated the importance of palliative care education and training, specifically in communication, symptom management, and continuing education. All nurses, including nursing students, transitioning nurses, and practicing nurses, should be trained to offer generalist (or primary) palliative care, in accordance with the American Association of Colleges of Nursing Essentials: Core Competencies for Professional Nursing Education. Provision of holistic, relationship-based, and integrated palliative care for patients and their families is an ethical obligation for all nurses.

Meanings and Experiences of End-of-Life Patients and Their Family Caregivers in Hospital-to-Home Transitions: A Constructivist Grounded Theory Study

This study explored the meanings and experiences of patients with terminal chronic diseases and their caregivers, who face the imminence of death in the home environment after hospital discharge. The qualitative study used constructivist grounded theory. The participants were individuals with a terminal chronic illness, discharged to home, and their family caregivers. Data were gathered from in-depth interviews and field notes, and a comparative analysis was conducted to identify categories and codes, according to Charmaz's theory. The sample consisted of 21 participants. Three inter-related data categories emerged: "Floating between acceptance and resistance: Perceiving the proximity of death", "Analysing the end from other perspectives: it is in the encounter with death that life is understood" and "Accepting the path: between the love of letting go and the love of wanting to stay". The categories translate the reconstruction of those facing end-of-life occurring in the home environment. It is amid the imminence of death that life gains intensity and talking about the finitude of life configures an opportunity to see life from other perspectives. Giving voice to individuals facing the mishaps of a terminal illness fosters the path to a comfortable death. For health professionals, it is an opportunity to provide structured and humanized care with an ethical attitude, in defence of human dignity.

Communication of palliative care needs in discharge letters from hospice providers to primary care: a multisite sequential explanatory mixed methods study

Background

The provision of palliative care is increasing, with many people dying in community-based settings. It is essential that communication is effective if and when patients transition from hospice to community palliative care. Past research has indicated that communication issues are prevalent during hospital discharges, but little is known about hospice discharges.

Methods

An explanatory sequential mixed methods study consisting of a retrospective review of hospice discharge letters, followed by hospice focus groups, to explore patterns in communication of palliative care needs of discharged patients and describe why these patients were being discharged. Discharge letters were extracted for key content information using a standardised form. Letters were then examined for language patterns using a linguistic methodology termed corpus linguistics. Thematic analysis was used to analyse the focus group transcripts. Findings were triangulated to develop an explanatory understanding of discharge communication from hospice care.

Results

We sampled 250 discharge letters from five UK hospices whereby patients had been discharged to primary care. Twenty-five staff took part in focus groups. The main reasons for discharge extracted from the letters were symptoms “managed/resolved” (75.2%), and/or the “patient wishes to die/for care at home” (37.2%). Most patients had some form of physical needs documented on the letters (98.4%) but spiritual needs were rarely documented (2.4%). Psychological/emotional needs and social needs were documented in 46.4 and 35.6% of letters respectively. There was sometimes ambiguity in “who” will be following up “what” in the discharge letters, and whether described patients’ needs were resolved or ongoing for managing in the community setting. The extent to which patients received a copy of their discharge letter varied. Focus groups conveyed a lack of consensus on what constitutes “complexity” and “complex pain”.

Conclusions

The content and structure of discharge letters varied between hospices, although generally focused on physical needs. Our study provides insights into patterns associated with those discharged from hospice, and how policy and guidance in this area may be improved, such as greater consistency of sharing letters with patients. A patient-centred set of hospice-specific discharge letter principles could help improve future practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-01038-8.

The impact of covid-19 on out-of-hours adult hospice care: an online survey

Background

Globally COVID-19 has had a profound impact on the provision of healthcare, including palliative care. However, there is little evidence about the impact of COVID-19 on delivery of out-of-hours specialist palliative care services in the United Kingdom. The aim of the study is to investigate the impact of the COVID-19 pandemic on the delivery of out-of-hours community-based palliative care services.

Methods

A national online census survey of managers of adult hospices in the United Kingdom was undertaken. Survey were emailed to managers of adult hospices (n = 150) who provided out-of-hours community palliative care services. Fifteen questions related specifically to the impact of COVID-19. Quantitative data were analysed using descriptive statistics and qualitative data were analysed using descriptive content analysis.

Results

Eighty-one responses to the survey were returned (54% response rate); 59 were complete of which 47 contained COVID-19 data. Findings indicated that COVID-19 impacted on out-of-hours community-based palliative care. To meet increased patient need, hospices reconfigured services; redeployed staff; and introduced new policies and procedures to minimize virus transmission. Lack of integration between charitably and state funded palliative care providers was reported. The interconnected issues of the use and availability of Personal Protective Equipment (n = 21) and infection control screening (n = 12) resulted in changes in nursing practices due to fear of contagion for patients, carers and staff.

Conclusions

Survey findings suggest that due to increased demand for community palliative care services, hospices had to rapidly adapt and reconfigure services. Even though this response to the pandemic led to some service improvements, in the main, out-of-hours service reconfiguration resulted in challenges for hospices, including workforce issues, and availability of resources such as Personal Protective Equipment. These challenges were exacerbated by lack of integration with wider healthcare services. More research is required to fully understand the implications of such changes on the quality of care provided.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00985-6.

Talking together in rural palliative care: a qualitative study of interprofessional collaboration in Norway

Background

Caring for people with palliative care needs in their homes requires close collaboration within and between primary and hospital care. However, such close collaboration is often lacking. Transitions of care are potentially unsafe and distressing points in a patient trajectory. Few studies have explored the experiences of healthcare professionals in the community who receive patients from hospital care and provide them with palliative care at home.

Objective

To explore how rural health professionals experience local and regional collaboration on patients in need of palliative care.

Methods

This was a qualitative focus group and interview study in rural Northern Norway involving 52 primary care health professionals including district nurses, general practitioners, oncology nurses, physiotherapists, and occupational therapists. Five uni-professional focus group discussions were followed by five interprofessional discussions and six individual interviews. Transcripts were analysed thematically.

Results

“Talking together” was perceived as the optimal form of collaboration, both within primary care and with specialists. Nurses and GPs had similar perceptions of their worst-case scenario in primary palliative care: the sudden arrival after working hours of a sick patient about whom they lacked information. These situations could be the result of a short notice transfer from secondary care or an emergency presentation after a crisis in patient management locally, the latter often resulting in a hospital admission. Participants missed timely and detailed discharge letters and in complex cases a telephone call or conference. Locally, co-location was perceived as advantageous for crucial communication, mutual support, and knowledge about each other’s competencies and work schedule. Because local health professionals belonged to different units within the primary health care organisation, in some places they had limited knowledge about each other’s roles and skill sets.

Conclusions

Lack of communication, both locally and between specialist and primary care, was a key factor in the worst-case patient scenarios for GPs and nurses working in primary palliative care in rural Northern Norway. Co-location of primary care professionals promoted local collaboration and should be encouraged. Hospital discharge planning should involve the receiving primary care professionals.

Quality of hospital discharge letters for patients at the end of life: A retrospective medical record review

Objective

For patients who are discharged to go home after a hospitalisation, timely and adequately informing their general practitioner is important for continuity of care, especially at the end of life. We studied the quality of the hospital discharge letter for patients who were hospitalised in their last year of life.

Methods

A retrospective medical record review was performed. Included patients had been admitted to the hospital during the period 1 January to 1 July 2017 and had died within a year after discharge.

Results

Data were collected from records of 108 patients with cancer or other diseases. For 57 patients (53%), the discharge letter included information that related to their limited life expectancy (e.g., agreements about treatment limitations), whereas the patient's limited life expectancy was addressed in the medical record in 76 cases (70%). We found related information in discharge letters for 36 patients (66%) who died <3 months compared to 21 patients (40%) who died 3–12 months after hospitalisation (p < 0.01).

Conclusion

For patients with a limited life expectancy going home after a hospitalisation, one out of two hospital discharge letters lacked any information addressing their limited life expectancy. Specific guidelines for medical information exchange between care settings are needed.

Examining the course of transitions from hospital to home-based palliative care: A mixed methods study

BACKGROUND

Hospital-to-home transitions in palliative care are fraught with challenges. To assess transitions researchers have used patient reported outcome measures and qualitative data to give unique insights into a phenomenon. Few measures examine care setting transitions in palliative care, yet domains identified in other populations are likely relevant for patients receiving palliative care.

AIM

Gain insight into how patients experience three domains, discharge readiness, transition quality, and discharge-coping, during hospital-to-home transitions.

DESIGN

Longitudinal, convergent parallel mixed methods study design with two data collection visits: in-hospital before and 3-4 weeks after discharge. Participants completed scales assessing discharge readiness, transition quality, and post discharge-coping. A qualitative interview was conducted at both visits. Data were analyzed separately and integrated using a merged transformative methodology, allowing us to compare and contrast the data.

SETTING AND PARTICIPANTS

Study was set in two tertiary hospitals in Toronto, Canada. Adult inpatients (n = 25) and their caregivers (n = 14) were eligible if they received a palliative care consultation and transitioned to home-based palliative care.

RESULTS

Results were organized aligning with the scales; finding low discharge readiness (5.8; IQR: 1.9), moderate transition quality (66.7; IQR: 33.33), and poor discharge-coping (5.0; IQR: 2.6), respectively. Positive transitions involved feeling well supported, managing medications, feeling well, and having healthcare needs met. Challenges in transitions were feeling unwell, confusion over medications, unclear healthcare responsibilities, and emotional distress.

CONCLUSIONS

We identified aspects of these three domains that may be targeted to improve transitions through intervention development. Identified discrepancies between the data types should be considered for future research exploration.

Evaluation of a Home-Based, Nurse Practitioner-led Advanced Illness Care Program

OBJECTIVES

In the United States, people with serious illness often experience gaps and discontinuity in care. Gaps are frequently exacerbated by limited mobility, need for social support, and challenges managing multiple comorbidities. The Advanced Illness Care (AIC) Program provides nurse practitioner-led, home-based care for people with serious or complex chronic illnesses that specifically targets palliative care needs and coordinates with patients' primary care and specialty health care providers. We sought to investigate the effect of the AIC Program on hospital encounters [hospitalizations and emergency department (ED) visits], hospice conversion, and mortality.

DESIGN

Retrospective nearest-neighbor matching.

SETTING AND PARTICIPANTS

Patients in AIC who had ≥1 inpatient stay within the 60 days prior to AIC enrollment to fee-for-service Medicare controls at 9 hospitals within one health system.

METHODS

We matched on demographic characteristics and comorbidities, with exact matches for diagnosis-related group and home health enrollment. Outcomes were hospital encounters (30- and 90-day ED visits and hospitalizations), hospice conversion, and 30- and 90-day mortality.

RESULTS

We included 110 patients enrolled in the AIC Program matched to 371 controls. AIC enrollees were mean age 77.0, 40.9% male, and 79.1% white. Compared with controls, AIC enrollees had a higher likelihood of ED visits at 30 [15.1 percentage points, confidence interval (CI) 4.9, 25.3; P = .004] and 90 days (27.8 percentage points, CI 16.0, 39.6; P < .001); decreased likelihood of hospitalization at 30 days (11.4 percentage points, CI -17.7, -5.0; P < .001); and a higher likelihood of converting to hospice (22.4 percentage points, CI 11.4, 33.3; P < .001).

CONCLUSIONS

The AIC Program provides care and coordination that the home-based serious illness population may not otherwise receive.

IMPLICATIONS

By identifying and addressing care needs and gaps in care early, patients may avoid unnecessary hospitalizations and receive timely hospice services as they approach the end of life.

Research Roundup

Synopses of a selection of recently published research articles of relevance to palliative care.