title: Enhancing provider knowledge and patient screening for palliative care needs in chronic multimorbid patients receiving home-based primary care.
abstract: This article describes a pilot model to increase palliative care (PC) knowledge and collaboration among providers and to systematically identify chronic multimorbid home care patients who would benefit from focused discussion of potential PC needs. Thirty health care providers from a home-based primary care team attended interdisciplinary trainings. The Palliative Performance Scale (PPS) tool was used to trigger discussions of potential palliative needs at team rounds for patients who scored below a cutoff point on the tool. Palliative Performance Scale implementation added little burden on nurses and triggered a discussion in 51 flagged patients. The tool successfully identified 75% of patients who died or were discharged. Screening was systematic and consistent and resulted in targeted discussions about PC needs without generating additional burden on our PC consult service. This model shows promise for enhancing collaborative patient care and access to PC.
authors.affiliation: Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA.
authors.forename: Tracy
authors.initials: T
authors.lastname: Wharton
authors.affiliation: Veterans Administration Ann Arbor Healthcare System, Geriatric Research, Educational, and Clinical Center, Ann Arbor, MI, USA Division of Geriatric and Palliative Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.
authors.forename: Erika
authors.initials: E
authors.lastname: Manu
authors.affiliation: Veterans Administration Ann Arbor Healthcare System, Geriatric Research, Educational, and Clinical Center, Ann Arbor, MI, USA Division of Geriatric and Palliative Medicine, University of Michigan Medical School, Ann Arbor, MI, USA cavitale@umich.edu.
authors.forename: Caroline A
authors.initials: CA
authors.lastname: Vitale
mesh_terms: D002908:Chronic Disease / Q000628:therapy*; D015897:Comorbidity; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006301:Health Services Needs and Demand / Q000706:statistics & numerical data*; D006699:Home Care Services / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008962:Models, Theoretical; D010166:Palliative Care / Q000706:statistics & numerical data*; D010865:Pilot Projects; D011320:Primary Health Care / Q000379:methods / Q000706:statistics & numerical data
keywords: chronic care; home care; interdisciplinary care; multimorbidity; palliative care; screening