Perspectives on Collaborative Palliative Care Delivery for Home Health Patients

Upon hospital discharge, medically complex patients are frequently referred for skilled nursing facility (SNF) care or skilled home health care (HHC). Both settings provide restorative and supportive services; however, the intensity of services, such as around the clock nursing support, are greater in SNF care. Both settings have high rates of rehospitalizations. However, individuals often desire to avoid care in an institutional setting, eager to return home and remain there. Supporting patients in the home allows for more targeted use of SNF by individuals that may lack housing and caregiver resources. Palliative care support has been identified as one mechanism for supporting seriously ill patients discharged to home with HHC. However, identifying patients with unmet palliative care needs and coordinating with healthcare teams across settings to support these patients is challenging. We sought perspectives from key stakeholders to learn how HHC can best assess and address unmet palliative needs.