Development and evaluation of a palliative-transitional home health care model

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ABSTRACT The overarching goal of this R21 proposal “Development and Evaluation of a Palliative-Transitional Home Health Care Model” is to engage key stakeholders including hospitalists, primary care providers, home health clinicians (e.g., nurses, physical therapists, social workers), patients, and informal caregivers, to develop, refine, and pilot test a Palliative-Transitional Home Health Care (PT HHC) model to provide enhanced support after discharge for patients with additional palliative and transitional care needs. Patients receiving HHC are older and sicker than patients who are discharged home without HHC, yet current HHC does not assess or address palliative care needs. Care models incorporating palliative care principles have reduced health care utilization and improved the quality of care delivery in hospitals, nursing homes, and skilled nursing facilities. However, care models that incorporate both transitional and palliative care in HHC are lacking. Through this work, we aim to improve care for HHC patients with additional palliative and transitional care needs. The specific aims of this project include: (1) To develop and refine a Palliative-Transitional HHC model through focus groups with clinicians, interviews with patients and caregivers, and expert advisory panel guidance, and (2) To implement and evaluate the acceptability and feasibility of a Palliative-Transitional HHC model. Our investigator team has experience using qualitative and implementation science methods to design, implement, and disseminate interventions. We plan to use the Practical, Robust Implementation and Sustainability Model (PRISM) framework with the embedded RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) evaluation model to design and evaluate the model. This innovative care model will create a new paradigm for HHC nurses and social workers to engage with patients and caregivers to discuss advance care planning, patient symptoms, and caregiver needs, and to communicate with the primary care provider to request specialty palliative and hospice referrals when needed. This proposal fits well within the topics of interest for NIA described in PA-18-503, including development and evaluation of a new HHC model that incorporates palliative care. We plan to prospectively test the model developed in this grant in a future pragmatic trial to evaluate the effect of the PT HHC model on outcomes including patient symptoms, caregiver burden, advance care planning documentation, emergency department visits, and hospitalizations.