Background: Early introduction of palliative care for medically complex patients can improve patient-centered outcomes. Yet, little is known about how to address these issues as patients are cared for by multiple teams in multiple care settings between hospital, home health care and primary care. Here we highlight clinician perspectives about introducing palliative care in the home health setting for medically complex patients after hospital discharge.

Methods: Qualitative data were collected through interviews with clinicians with expert advisory panel guidance. Interview guides involved questions about participants’ experiences with palliative and transitional care delivery and additional needs to implement (or receive) palliative and transitional care. To date, we have conducted a total of 38 interviews with home health providers (n=10), hospitalists (n=11), and primary care providers (n=17). Our multidisciplinary team used directed content analysis to analyze interviews using an iterative, team-based approach to coding. We then entered the coded data into Atlas.ti 9.0 for data management and analyzed the data within and across interviews to develop major themes.

Results: Our analyses show that, for patients transitioning from the hospital to home health care, clinicians from different settings (including hospitalists, primary care, and home health) can help identify palliative care needs based on their unique perspective of the patient’s care. However, participants reported that doing so is challenging due to infrequent communication among clinicians who may not have access to the same information about each patient. Participants thought that the lack of regular communication between hospitalist, primary care, and home health clinicians made it more difficult to identify palliative care needs and to determine the best way to introduce and deliver palliative care (and by whom). Our findings suggest that early identification of the lead of care for each patient (typically, the primary care provider or a specialist) to bridge communication between multi-setting team members would improve the frequency and quality of palliative care delivery and ongoing goals of care discussions with patients and caregivers.

Conclusions: Our findings show that a lack of shared information and communication within multi-setting teams is a major barrier to identification of unmet palliative care needs and to addressing these needs among medically complex patients discharged with home health care. We propose an approach that involves 1) drawing on the unique perspective of team members in each setting to identify palliative care needs, 2) ongoing structured communication between the lead of care and home health and 3) introducing the topic of palliative care to patients and caregivers with collaborative provider dyads that may include the primary care provider and a home health social worker. This approach could improve patient acceptance of primary palliative care by increasing the consistency of information that patients and caregivers receive about palliative care across clinicians, de-stigmatizing palliative care, and drawing on the team’s combined knowledge about each patient’s health and preferences. The success of this approach relies on open channels of communication between providers. Future work should address institutional and policy considerations that may impact the feasibility of a multi-setting approach to palliative care delivery, including reimbursement across care settings.