Admission to hospice residence requires one or more transitions between care settings. Transitioning patients to hospice after emergency department (ED) arrival is challenging due to lack of clarity regarding goals of care, hospice access, and sporadic arrivals. Few patients have historically transitioned straight from the ED to hospice, despite the possible advantages for both patients and the healthcare system.
In this article, Baugh and colleagues (2024) describe the design and implementation of a care transitions program (CTP) with the primary objective of improving the timeliness of goal-concordant hospice care, for patients identified by their care team to be near end of life and eligible for hospice.
This quality improvement initiative was implemented at Brigham and Women’s Hospital in Boston, Massachusetts and utilized a pre-post quality improvement study design. The control period, prior to CTP implementation, was from September 1, 2018, to January 31, 2020. The intervention period was from August 1, 2021, to December 31, 2022.
A team of professionals from various fields, including physicians, nurses, social workers, ED care coordinators, palliative care staff, specialty service staff, and data scientists, collaborated on workflow development of the ED CTP. Key features of the program included:
- Screening of potential candidates for hospice using near–real-time data from the electronic health record, alerting care coordinators via email.
- Dedicated rounding to identify candidates early.
- Biannual virtual training on CTP and hospice benefits provided to ED clinicians.
- Multidisciplinary decision between ED care facilitator and hospice partner to determine patient eligibility. Ineligible patients were provided with a palliative care consultation.
- The ED care facilitator and hospice partner determined whether the patient was eligible for GIP hospice and, if not eligible, ensured palliative care consultation.
- Point-of-care tip sheets.
- Optimization of hospice admission orders.
- Creation of data reporting, including tracking of eligible patients not enrolled in the hospice pathway.
- Weekly multidisciplinary case reviews.
The primary outcome measure was a planned transition to hospice without inpatient hospital admission within 96 hours of the ED visit. Secondary outcomes included hospice type, inpatient and ED length-of-stay (LOS), and in-hospital mortality. Additionally, differences between subgroups with cancer and neurologic conditions were analyzed.
Overall, 54.1% of patients achieved the primary outcome of goal-concordant transition to hospice within 96 hours during the intervention compared with 22.6% in the control period. A higher proportion of patients in the intervention group transitioning to a hospice prior to death than in the control group. There was no difference in inpatient or ED LOS between the control and intervention cohorts.
This study illustrates that alternative pathways for avoiding unnecessary hospital admissions for patients near the end of life are feasible and associated with increased goal-concordant hospice use.
Source: Baugh, C. W., Ouchi, K., Bowman, J. K., Aizer, A. A., Zirulnik, A. W., Wadleigh, M., … & Mendu, M. L. (2024). A Hospice Transitions Program for Patients in the Emergency Department. JAMA Network Open, 7(7), e2420695-e2420695.
Visit our Research Page to read more about recent hospice palliative care research.
