SHM Converge Scientific Abstract ePoster Gallery-A Multi-Setting Approach to Palliative Care Discussions With Patients Transitioning From the Hospital to Home Health Care

Pdf Summary

This study examined how a coordinated, multi-setting approach could improve early identification of palliative care needs for patients transitioning from the hospital to home health care. Researchers conducted semi-structured Zoom interviews with 38 participants: 10 home health clinicians/staff, 11 hospitalists, and 17 primary care providers.<br /><br />Four key themes emerged. First, clinicians in different settings can each recognize palliative care needs because they see patients from different perspectives. Second, identifying these needs is difficult because communication and information sharing between settings are often poor. Third, participants emphasized the importance of a lead of care for each patient—often the primary care provider—to direct palliative care discussions with the patient and family. Fourth, they also identified the need for a lead of communication to connect providers across settings and ensure timely, clear information transfer.<br /><br />The findings suggest that palliative care identification should not rely on a single clinician or setting. Instead, it should be a shared process supported by clear ownership of care and communication. Participants described how better coordination could help address complex situations involving repeated hospitalizations, caregiver strain, symptom burden, and unmet emotional support needs.<br /><br />Overall, the study concludes that a multi-setting approach, centered on both a lead of care and a lead of communication, may improve early palliative care discussions and allow earlier interventions for patients and caregivers across hospital, primary care, and home health settings.

Asset Subtitle

Christine D. Jones

Meta Tag

Author List Amy Huebschmann, Ashley Dafoe, Caroline Tietbohl, Christine D. Jones, Hillary Lum, Sarah Jordan

Category Research

Concept Palliative Care

Concept Unmet Palliative Care Needs

Concept Hospital-to-Home Transition

Concept Home Health Care

Concept Communication Barrier

Distinguished Non-Finalist

Presenter Organization University of Colorado and Rocky Mountain Regional VA Medical Center

Presenting Author Christine D. Jones

Track Transitions of Care

Keywords

palliative care

early identification

hospital to home transition

home health care

primary care providers

hospitalists

care coordination

communication across settings

lead of care

lead of communication

Palliative Care

Unmet Palliative Care Needs

Hospital-to-Home Transition

Home Health Care

Communication Barrier