P0561 - Symptom Management Plan for Palliative Homecare Patients – A Quality Improvement Project to Empower Caregivers

Preventable hospitalizations and emergency department (ED) visits can be reduced by caregiver home management of symptoms. Our institution’s palliative homecare program provides care coordination and unique home-based support for children with chronic complex medical conditions. Despite this, hospital resource utilization in this population remains high. We identified variability in availability and format of “sick plans” as potential drivers of unplanned visits to the emergency room and admissions.

SMART

Aim: Within 6 months, ≥ 90% of palliative homecare patients will have a Symptom Management Plan (SMP) reviewed with the caregiver and ˃ 25% of caregivers will report improved confidence in management of symptoms at home.

An inter-professional team was formed including the director of homecare, manager of homecare clinical services, homecare nurses, homecare social workers, director of palliative medicine, clinical informaticists, and pulmonary, neurology, and gastroenterology subspecialists. Key Driver (Figure 1) and Ishikawa diagrams were used to assess caregivers’ barriers to initiation of “sick plans.” An Electronic Health Record (EHR)-based SMP template was created for common symptoms: respiratory distress, seizures, feeding intolerance, and constipation, with core subspecialists’ input. Individualized SMPs were created and reviewed with caregivers at palliative home nursing visits with regular review at every visit. Caregivers were surveyed on confidence in management of symptoms 6 months post-implementation. Resource utilization was analyzed prior to implementation of SMP and 6 months post-implementation.

Six months after implementation of the SMP, 89% of palliative homecare patients had individualized SMPs created (Figure 2), and plans were reviewed with the caregiver within 1-2 months. Six-month post-implementation data shows that 73% of caregivers report “better” or “much better” confidence in symptom management, and 76% perceived the SMP prevented unplanned ED and urgent care visits (n=33). Of 44 who remained in homecare the entire study period, the mean 6-month pre-SMP ED visits compared to post-SMP were 1.55 ± 2.32 vs. 0.89 ± 1.19 (p = 0.04), and the mean 6-month pre-SMP admissions compared to post-SMP were 1.25 ± 1.63 vs 0.52 ± 0.79 (p = 0.005).

We successfully created an EHR-based SMP for children with medical complexity receiving palliative homecare. We approached our goal of ≥ 90% individualized SMP review at 6 months and exceeded this by month 7. Survey data shows greatly improved self-reported confidence in home symptom management 6 months post-implementation. Hospital utilization (ED visits and admissions) decreased 6 months after implementation of SMP. Next cycles will include release of Spanish template and translation workflow and dissemination across subspecialty clinics.