A quality improvement intervention to increase palliative care in nursing homes. Improving the use of hospice services in nursing homes: a randomized controlled trial.
Death is common in nursing homes, but access to palliative care is limited.
                To test whether a quality improvement (QI) intervention in nursing homes increases hospice, pain management, and advance care planning.
                The QI intervention was tested in seven nursing homes using a prepoststudy design. Two additional nursing homes served as control sites.
                Nine nursing homes serving 1169 residents.
                The intervention included recruitment and training of Palliative Care Leadership Teams in each facility, followed by six technical assistance meetings for team members. Hospice providers delivered six educational sessions for all nursing home staff using a structured curriculum. Teams received feedback of performance data on hospice enrollment, pain management, and advance care planning at 0, 3, and 6 months.
                Percentage of residents receiving hospice or palliative services, pain assessment, pain treatment among residents in pain, and documented advance care planning discussions.
                Intervention facilities increased hospice enrollment from 4.0% of residents at baseline to 6.8% postintervention (p = .01) and increased pain assessments from 18% to 60% (p < .001). Among resident in pain, orders for nonpharmacologic pain treatments increased from 15% to 35% (p < .001), but pain medication use did not change. Residents with in-depth discussions about end-of-life care increased from 4% to 17% (p < .001). There were no significant changes in control sites.
                A quality improvement intervention was effective in increasing hospice enrollment, pain assessment, nonpharmacologic pain treatment, and advance care planning discussions. Hospice care may improve the quality of end-of-life care for nursing home residents, but hospice is underutilized by this population, at least in part because physicians are not aware of their patients' preferences.
                To determine whether it is possible to increase hospice utilization and improve the quality of end-of-life care by identifying residents whose goals and preferences are consistent with hospice care.
                Randomized controlled trial (December 2003-December 2004) of nursing home residents and their surrogate decision makers (N=205) in 3 US nursing homes.
                A structured interview identified residents whose goals for care, treatment preferences, and palliative care needs made them appropriate for hospice care. These residents' physicians were notified and asked to authorize a hospice informational visit.
                The primary outcome measures were (1) hospice enrollment within 30 days of the intervention and (2) families' ratings of the quality of care for residents who died during the 6-month follow-up period.
                Of the 205 residents in the study sample, 107 were randomly assigned to receive the intervention, and 98 received usual care. Intervention residents were more likely than usual care residents to enroll in hospice within 30 days (21/107 [20%] vs 1/98 [1%]; P<.001 [Fisher exact test]) and to enroll in hospice during the follow-up period (27/207 [25%] vs 6/98 [6%]; P<.001). Intervention residents had fewer acute care admissions (mean: 0.28 vs 0.49; P = .04 [Wilcoxon rank sum test]) and spent fewer days in an acute care setting (mean: 1.2 vs 3.0; P = .03 [Wilcoxon rank sum test]). Families of intervention residents rated the resident's care more highly than did families of usual care residents (mean on a scale of 1-5: 4.1 vs 2.5; P = .04 [Wilcoxon rank sum test]).
                A simple communication intervention can increase rates of hospice referrals and families' ratings of end-of-life care and may also decrease utilization of acute care resources.
We found few studies, and all were in the USA. Although the results are potentially promising, high quality trials of palliative care service delivery interventions which assess outcomes for residents are needed, particularly outside the USA. These should focus on measuring standard outcomes, assessing cost-effectiveness, and reducing bias.