A quality improvement intervention to increase palliative care in nursing homes. A palliative-care intervention and death at home: a cluster randomised 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. The Palliative Medicine Unit at University Hospital of Trondheim, Norway, started an intervention programme that aims to enable patients to spend more time at home and die there if they prefer. Close cooperation was needed with the community health-care professionals, who acted as the principal formal caregivers, and a multidisciplinary consultant team coordinated the care. We did a cluster randomised trial to assess the intervention's effectiveness compared with conventional care
                Community health-care districts in and around Trondheim, Norway, were defined as the clusters to be randomised. We enrolled 434 patients (235 assigned intervention and 199 conventional care [controls]) in these districts who had incurable malignant disease and an expected survival of 2-9 months. Main outcomes were place of death and time spent in institutions in the last month of life.
                395 patients died. Of these, more intervention patients than controls died at home (54 [25%] vs 26 [15%], p<0.05). The time spent at home was not significantly increased, although intervention patients spent a smaller proportion of time in nursing homes in the last month of life than did controls (7.2 vs 14.6%, p<0.05). Hospital use was similar in the two groups.
                The palliative-care intervention enabled more patients to die at home. More resources for care in the home (palliative care training and staff) and an increased focus on use of nursing homes would be necessary, however, to increase time at home and reduce hospital admissions.
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.