Community-Based Palliative Care: Care Transitions and Beyond (SA532)

Abstract

•Describe the conceptual and pragmatic elements of an innovative model of transitional care for patients with advanced illness.•Identify the critical elements of the High-Touch model of palliative care and link clinical interventions to outcomes.•Describe the impact of an interdisciplinary High-Touch model of community-based specialist palliative care through the experience of a patient with advanced heart failure. Palliative care in the United States has been characterized by recognition as a medical specialty, rapid growth in programs, and proliferation in the development of diverse models. However, with a rapidly aging population, workforce shortages, lack of access for some patients, and a new policy impetus toward community-based palliative care, novel models with sound clinical and research outcomes are urgently needed to promote access and ensure quality. This presentation will highlight best clinical and research practices using two different models of palliative care, transitional care, and the High Touch model of palliative care. First, Dr Myra Glajchen, a palliative care educator and researcher, will describe a novel model of transitional care for older patients with advanced illness, highlighting complex practical tasks, emotional challenges, and systems problems; and share innovative tools and practices, including an interdisciplinary approach, templated assessment, handoffs and community-based intervention and links between the hospital and community-based settings. Second, Dr Lara Dhingra, a palliative care researcher and psychologist, will highlight the essential clinical and program components of the High-Touch model of palliative care, linking research findings from a large dataset of palliative care patients to best practices and clinical outcomes. Third, Dr Bernard Lee, a palliative care specialist, will illustrate the impact of the High-Touch model on a patient with advanced medical illness and complex needs, tracing the patient experience from diagnosis through hospitalization, discharge, community-based care, and hospice. Participants will be asked to identify clinical and systems barriers in the case and engage in treatment decision-making, drawing upon challenging clinical scenarios in their own practice. Audience members will emerge with new knowledge about models of care and steps for translating important research findings into their own practice with implementation tools and best practice guidelines for maintaining the patient in the home setting.