Risk Factor Assessment of Hospice Patients Readmitted within 7 Days of Acute Care Hospital Discharge

Building Bridges in Palliative Rehabilitation: An Evidence-Based Toolkit to Promote Collaboration

Background: Palliative care and rehabilitation professionals caring for seriously ill people and their families face barriers to effective, timely collaboration. Barriers such as ineffective communication processes, role misunderstanding across professions, and resource limitations can lead to underutilization of rehabilitation services for this vulnerable population. Objectives: To create practical connections between palliative care and rehabilitation professionals and to provide tools and strategies for teams to develop the core competencies (role clarity, communication, teamwork, and shared values) necessary to provide coordinated, timely, effective care to people living with serious illness. Design: With Interprofessional Education Collaborative (IPEC) Core Competencies1 as a framework for interprofessional collaborative practice, a quality improvement project was conducted at a large academic medical center. The 5-phase project included literature review, expert interviews, identification of barriers and facilitators, development of strategies to mitigate barriers, and pilot testing of select strategies. Results: The PalRehab Toolkit consists of strategies to enhance interprofessional collaborative practice and infuse rehabilitation into palliative care in the acute care setting. Preliminary evaluation of piloted strategies suggests increased communication across professions, improved role clarity, and an increased likelihood of collaboration. Conclusion: Providing educational offerings, establishing efficient communication channels, and infusing rehabilitation concepts into palliative care practices, as outlined in the PalRehab Toolkit, may positively impact interprofessional collaborative practice and improve care delivery for people with serious illness and their families.

Hispanics and Hospice: A Systematic Literature Review

Background. Hospice has been shown to improve patient and family satisfaction with care, reduce hospitalizations and hospital costs, and reduce pain and symptoms. Despite more than 40 years of hospice care and related research in the U.S., few studies examining hospice experiences have included Hispanics. Thus, little is known about hospice barriers, facilitators, and outcomes among Hispanics.Aim. This systematic literature review aimed to provide a comprehensive overview of studies assessing knowledge of and attitudes toward hospice, barriers and facilitators to hospice use, utilization patterns, and hospice-related outcomes among Hispanics.Design. Between March 2019 and March 2020 we searched Ovid Medline (PubMed), EMBASE, and CINAHL, using search terms for hospice care, end-of-life care, Hispanics, and Latinos. All steps were guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols. U.S. studies that examined Hispanics' knowledge and attitudes towards hospice, facilitators or barriers to hospice use, hospice use, and hospice-related outcomes were included. Qualitative studies and non-empirical work were excluded. Study quality was assessed using Hawker's quality criteria.Results. Of the 4,841 abstracts reviewed, 41 peer-reviewed articles met the inclusion criteria. These studies largely report lower hospice knowledge and awareness among Hispanics and mixed results around hospice use and outcomes in comparison to Whites.Conclusion. There has been relatively little research focused specifically on Hispanics' experience with hospice. Future research should focus on testing interventions for overcoming hospice-related disparities among Hispanics and on improving access to quality hospice care among terminally ill Hispanics.

Characteristics and Procedures Among Adults Discharged to Hospice After Gastrointestinal Tract Surgery in California

IMPORTANCE

Hospice care is associated with improved quality of life and goal-concordant care. Limited data suggest that provision of hospice services after surgery is suboptimal; however, literature in this domain is in its nascency, leaving gaps in our understanding of patients who enroll in hospice after surgery.

OBJECTIVE

To characterize the transition to hospice after gastrointestinal tract surgery and identify areas that warrant further attention and intervention.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included patients discharged to hospice after a surgical hospitalization for a digestive disorder in California-licensed hospitals between January 1, 2015, and December 31, 2019. Data were analyzed from August 1 to November 30, 2021.

EXPOSURES

Patient age, race and ethnicity, principal language, payer, and Distressed Community Index (DCI).

MAIN OUTCOMES AND MEASURES

Admission type and most common diagnoses and procedures for surgical hospitalizations that resulted in discharge to hospice, annual hospitalization trend for 3 years preceding hospice enrollment, and most common diagnoses for patients who were readmitted after hospice enrollment were summarized. Age, race and ethnicity, principal language, payer, and DCI were compared between patients who were readmitted after hospice enrollment and those who were not.

RESULTS

Of 2688 patients with surgical hospitalizations resulting in discharge to hospice (mean [SD] age, 73.2 [14.7] years; 1459 women [54.3%]), 2389 (88.9%) had urgent or emergent discharges. The most common diagnoses were cancer (primary and metastatic; 1541 [57.3%]) and bowel obstruction (563 [20.9%]). The most common procedures were bowel resection, fecal diversion, inferior vena cava filter, gastric bypass, and paracentesis. In the 3 years preceding hospice enrollment, this cohort had a mean (SD) of 2.21 (2.77) hospitalizations per patient (1537 of 5953 surgical [25.8%]). Of these, 3594 of 5953 total (60.4%) and 840 of 1537 surgical (54.7%) hospitalizations were within 1 year of hospice enrollment. Three hundred and sixty-eight patients (13.7%) were readmitted after hospice enrollment, with infection being the most common readmission diagnosis. Readmitted patients were more likely to be younger (mean [SD] age, 69.7 [16.4] vs 73.8 [14.3] years; P < .001), to speak a principal language other than English (62 of 368 [16.8%] vs 292 of 2320 [12.6%]; P = .02), to be insured through Medicaid (70 of 368 [19.0%] vs 223 of 2320 [9.6%]; P < .001), and to be from a community with higher DCI (198 of 360 [55.0%] vs 1117 of 2269 [49.2%]; P = .04) and were less likely to be White (195 of 368 [53.0%] vs 1479 of 2320 [63.8%]; P < .001).

CONCLUSIONS AND RELEVANCE

These findings suggest multiple opportunities for advance care planning in this surgical cohort, with a particular focus on emergent care. Further study is needed to understand the reasons for rehospitalization after hospice discharge and identify ways to improve communication and decision-making support for patients who choose to enroll in hospice care. Given the frequent antecedent interactions with the health care system among this population, longitudinal and tailored approaches may be beneficial to promote equitable end-of-life care; however, further research is needed to clarify barriers and understand differing patient needs.

Hospital Readmissions in Hospice Patients: Evaluation of Medication-Related Causes for Readmission

CONTEXT

Hospital readmissions, frequent medication changes, and polypharmacy are common issues for hospice patients. It is important to consider if close monitoring of medications by pharmacists could help these patients avoid hospital readmissions.

OBJECTIVE

The objectives of this study were to determine the incidence and types of medication-related problems that contributed to hospital readmissions from hospice settings.

METHODS

A retrospective chart review was conducted from October 1, 2018 to January 31, 2020. Patients admitted from hospice settings (i.e. Home, ALF, LTCF) and who were seen by the palliative care teams at 9 Maryland and Washington DC MedStar hospitals were included. Demographic information was collected: age, gender, race, primary hospice diagnosis, prognosis determined by provider prior to hospice disposition, reason for readmission, and medication list at readmission. The primary outcomes were the incidence and types of medication-related problems. Secondary outcomes included patient characteristics associated with readmission, and classes/number of medications changed before readmission. Descriptive statistics were used to analyze data.

RESULTS

Seventy-five hospice patients were readmitted and seen by palliative care during the study period. Forty-three patients (57%) were found to have medication-related problems at readmission. The most common problem identified was needing additional drug therapy. Dose too low, dose too high, incorrect drugs, adverse drug reactions, and non-adherence were also identified. Additional reasons for readmission were: unanticipated new medical issue (n = 46, 61%) and uncontrolled symptoms (n = 34, 34%).

CONCLUSIONS

These findings suggest that deprescribing practices possibly contributeto readmissions from hospice settings.

Incidence and Characteristics Associated with Hospital Readmission after Discharge to Home Hospice

Background: Home hospice is designed to provide comfort to patients at the end of their life and hospital readmission is incongruent with this goal. Objective: The purpose of this study was to investigate the incidence of and characteristics associated with hospital readmissions from home hospice over a two-year period. Design/Subjects: This was a retrospective cohort study of 705 inpatients discharged from a quaternary academic medical center to home hospice from January 1, 2016 to December 31, 2017. Measures: The primary outcome was incidence of hospital readmission after discharge to home hospice. Multivariate regression with stepwise forward selection was used to identify characteristics associated with readmission. Results: The incidence of readmission was found to be 10.50% (n = 74), and the median days from discharge to readmission were 32.50 days (interquartile range = 14.00, 75.00). Reasons for readmission were: unanticipated new medical issue (n = 33, 44.59%), uncontrolled symptoms (n = 25, 33.78%), misunderstanding of hospice status (n = 12, 16.22%), and caregiver distress (n = 4, 5.41%). The following characteristics were associated with readmission: female versus male (odds ratio [OR] = 1.96; 95% confidence interval [CI]: 1.16-3.32), non-white versus white (OR = 2.40; 95% CI: 1.36-4.24), and hospice diagnosis of cardiac disease versus all other diagnoses (OR = 4.40; 95% CI: 2.06-9.37). Conclusions: Compared with prior studies, our findings showed a lower incidence of readmission, 10.50%, from home hospice. In addition, those who are female, non-white, or have a hospice diagnosis of cardiac disease are more likely to be readmitted.