Assessment and Management Tools for Advancing Disease.

Area of Science:

• Gerontology
• Palliative Care
• Home Healthcare

Background:

• The aging US population has led to an increase in home care patients with multiple chronic diseases.
• Literature suggests palliative care principles can improve outcomes for patients with advancing disease.

Purpose of the Study:

• To educate home care staff on palliative care principles and tools.
• To improve symptom identification and management, prevent hospitalizations, and reduce costs for home care patients.

Main Methods:

• A quality improvement project involving eight home care agency offices in Kentucky and Indiana.
• Mandatory 5-month education sessions for nurses, social workers, and therapists on palliative care integration, Edmonton Symptom Assessment Scale (ESAS), and end-of-life planning.
• Tracking and management of patient symptoms, with analysis of ESAS scores and hospitalization rates.

Main Results:

• Some patient symptoms worsened during the episode of care, indicating a need for enhanced staff training.
• Hospitalization and rehospitalization rates and costs were compared and benchmarked.
• The study highlighted the need for individualized care and potentially extended home healthcare.

Conclusions:

• While palliative care integration shows promise, additional staff training on symptom management is crucial.
• Individualized care plans and formal palliative care education are recommended for home care staff.
• The project underscores the importance of addressing symptom complexity in advancing disease within home care settings.