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Bridging the Gap Between Home Care and Hospice

Monday August 25, 2008
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Recognizing that patients with advanced illness have unique needs, the Visiting Nurse Service of New York (VNSNY) has piloted a program that seeks to build a bridge between ongoing active treatment and palliative care. Success will be measured in the form of more knowledgeable patients and families, increased use of hospice services, decreased emergency hospitalizations, and greater job satisfaction for nurses.

Supported by an $864,837 grant from the New York State Health Foundation in 2007, the VNSNY and its research arm, the Center for Home Care Policy & Research (CHCPR), have great hopes for the program, based on results produced to date. Officially titled "Establishing an Advanced Illness Management (AIM) Model in a Community-based Setting: Innovation at the Visiting Nurse Service of New York," the pilot program seeks to redefine best practices for home-based end-of-life care. The goals are to create a model program that makes greater use of palliative and hospice care and reduces the unnecessary use of acute care services, and to build a business case for an Advanced Illness Model that Medicaid- and Medicare-certified home care services can replicate.


Penny Hollander Feldman, PhD
Penny Hollander Feldman, PhD, vice president for Research and Evaluation at VNSNY and director of the CHCPR, says the project involves about 800 patients and nine healthcare teams from the VNSNY Queens office, divided into intervention and control groups. The Queens office was chosen because it serves such a diverse patient population and has such strong cultural underpinnings. It is expected that as many as 475 patients will have received AIM intervention services by the end of the project.

"This is a very exciting study with several important objectives that reinforce each other," Feldman says. They are to increase discharge to hospice among hospice-eligible patients in the home health agency; to improve palliative care for those patients who choose and are eligible to remain in home health care; and to reduce the number of hospitalizations. "These patients tend to spiral downward, going from one emergency room visit to another, because they aren't aware of other options," Feldman says. "The ultimate aim is to proactively develop tailored care plans for patients with advanced illness and help them to understand their plans." To accomplish this, specially trained VNSNY nurses discuss these topics with patients and their family members as early as possible in the illness trajectory and try to implement plans that will keep patients at home.

VNSNY hired advanced practice nurses to train and mentor their front-line nurses to become clinical resource nurses (CRNs) for the home care teams. The APNs doing the training use a number of approaches. They adapted a standard palliative care training course that is used nationally to give trainees an overview at the beginning of the study. Then they did one-on-one training and role-playing to give the nurses practice at discussing sensitive topics with patients. Finally, they accompanied the CRNs on patient visits and debriefed them after the visits about things they could improve. "The average nurse has no training in broaching issues surrounding death," Feldman says. "They don't want to upset the patient, so they avoid the issue." Often, she says, everyone involved knows the situation and is relieved to talk about it with the nurse. "It is very satisfying for the nurse to see how this discussion helps the patient and family," she says.

Karol Dibello, FNP, MS, BC, ACHPN, and Geraldine Abbatiello, RN, APN, PhD, developed the CRN training program. Now that initial training is over, the two meet with the CRNs every two weeks and develop educational resources for them. Dibello says the biggest challenge has been in helping the CRNs to become active listeners. "Nurses are moved to action," Dibello says. "I have had to convince them that they don't have to be 'doing' all the time. Sitting and listening is important, too." She acknowledges that listening adds time to each visit, so she tries to help the CRNs to ask questions in ways that will keep the home care visits on track.


The VNSNY AIM Project Research Team. From left: Geraldine Abatiello, PhD, APN, RN, clinical nurse specialist for AIM Project ; Beth Costello, MA, Research Analyst; Jennifer Mongoven, MPH, Senior Research Project Manager; Karol Di Bello, MS, FNP, RN, ACHPN, clinical nurse specialist for AIM Project; Miriam Ryvicker, PhD, Research Associate/Project Manager; Marilyn Liota; MA, BSN,RN, Queens Regional Administrator.
(Janet Charles, Janet Charles Photo)
As the CRNs help patients to make plans before an emergency occurs, they also can focus more on pain and symptom management. Feldman says that this all will become second nature to resource nurses after enough experience at it, and time won't be such an issue. The benefit of keeping these patients out of emergency rooms, meanwhile, has a positive effect on the entire healthcare system, saving time and human resources on that side of the equation.

Lilleth Carona Thompson, RN, MSN, a CRN trainee, says that the program has helped her to take a more holistic approach to her patients. Thompson recalls a patient in her early 70s who was diagnosed with cancer. She wasn't the biggest fan of nurses when Thompson and Karol Dibello entered her life. They gave her the opportunity to talk about whatever she wanted, which allowed her to get the information she wanted without delving too deeply into all the facts. They got her physical symptoms under control and encouraged her to move in with her daughter something she had been considering but was afraid to do. They made the arrangements to have homecare services provided at her daughter's home, and with her pain under control, she moved in and enjoyed her last days surrounded by family. "She died a peaceful person," Thompson says. "She and her daughter needed and appreciated our help."

When the pilot program ends in December, Feldman will meet with the staff involved, review and analyze all the data, and develop the recommendations, including the business case for the VNSNY all by June 2009. She is enthusiastic and optimistic about the project because it meets a major need for patients. "I am eager to see the results and anticipate that they will be positive," she says.


Vikki Newton is writer, editor, and owner of Vikki Newton Editorial Consulting.To comment, e-mail editorNY@nursingspectrum.com.