Creating a bridge between hospital and home in palliative care - using a hospital to home project.
Introduction: Many studies describe the disconnect between hospital-based palliative care and the care provided at home. Issues include a ‘gap’ between discharge from hospital and admission to community palliative care services, challenges in information transfer and fragmented discharge planning. This presentation discusses a joint project between an acute hospital palliative care service and a home-based palliative care service, to address these issues.
Aim: to smooth the transition for clients receiving palliative care, as they transfer between hospital and homecare environments.
Approach: Over a six-month period, data was collected regarding key aspects of care, when a client was transferred home from hospital. Analysis indicated a lengthy period between a referral to homecare and the first home visit; little attention to discussion about end of life care issues; inadequate medication orders; and a high proportion of readmissions to hospital.
Funding was received by the acute hospital to establish a hospital liaison nurse in collaboration with the homecare service, to focus care on comprehensive assessment and planning for those being referred to homecare. The role is fluid, being co-located, providing inpatient and home visits; it enables prioritising of care for patients being transferred home and leads discharge coordination between settings.
Outcomes and discussion: This position commenced in February 2020. Key outcomes data continues to be collected and will be reported. Anticipated improvements will be in the timeliness and appropriateness of all aspects of discharge planning.
Conclusion: The Hospital Liaison Nurse role has the potential to demonstrate increased service integration and improved client outcomes. More prompt responses following discharge and fewer readmissions represents a financial incentive for continuing development of the role.