Home Is Where the Heart Is: The Impact of Home-Based Palliative Care on Patients with Advanced Heart Failure

Abstract

Introduction There is growing interest in the effect that specialty palliative care (PC) has on outcomes for patients with advanced heart failure (HF). Some evidence suggests that PC may improve quality of life, understanding of prognosis, and documentation of treatment preferences but that it does not affect hospitalization or mortality. Objectives To determine the effect of home-based PC on documentation of treatment preferences and healthcare utilization for patients with advanced HF. Methods A community-based non-profit hospice and PC organization partnered with the heart failure clinic at a general hospital that is a member of a large, state-owned, academic health system. The clinic referred patients with advanced HF to a 30-day program with weekly visits from a PC RN for ongoing physical and symptom assessment, medication reconciliation, advance care planning, home safety evaluation, and psychosocial support. Additional involvement from PC SW, NP, and MD was available as needed. Outcomes included discussion and clarification of code status, discussion and completion of health care power of attorney (HCPOA), and 30-day health care utilization for patients admitted to the program compared to 90 days prior to admission. Results Over 13 months, 40 patients were referred to the program. Of those, 29 agreed to admission, 7 declined admission but enrolled in other services such as hospice, and 4 declined admission and any services. During the 30-day program, code status was discussed with all 29 patients (100%). On admission, code status was “Full” for 23 patients (79%). After 30 days, 11 patients changed their code status to “DNR.” HCPOA completion was discussed with 25 patients (86%). On admission, 15 patients (52%) of patients already had completed a HCPOA. After 30 days, an additional 7 patients completed a HCPOA. On discharge from the program, 17 patients (59%) continued with PC services, 6 (21%) declined follow up, 5 (17%) enrolled in hospice, and 1 (3%) died prior to discharge. Compared to 90 days prior to admission, hospitalizations for the 29 admitted patients decreased 70% from 0.47 hospitalizations per patient per 30 days to 0.14 during the program. Hospitalization length of stay (LOS) decreased 92% from 2.64 days per patient per 30 days to 0.21. Conclusions A 30-day home-based PC program for patients with advanced HF did increase documentation of treatment preferences such as code status and completion of HCPOA. Hospitalizations and hospitalization LOS were reduced during the program when compared to 90 days prior to program admission.