Document Type

DNP Project

Publication Date



Background: The lack of palliative care (PC) services poses a significant risk for PC patients. Research indicates that patients' needs often go unmet when PC referral processes are not well established within a health system. Furthermore, PC patients have higher readmission rates, thus increasing health care costs. PC referrals improve the quality of care while also reducing readmissions. Purpose: The purpose of this project was to determine whether PC referrals impacted the readmission rates of chronically and terminally ill patients. Methods: A 2018 practice assessment of an Indiana community hospital revealed a high rate of readmissions among chronically and terminally ill patients. An evidence-based process improvement project was implemented, guided by the Iowa model, in which a sample of 22 terminally and chronically ill patients were identified and referred for PC. Following PC training, risk assessment scores were used to identify PC patients appropriate for referral, after which case managers provided follow-up over the course of six months. Results: Six months before implementation, the sample (n = 22) recorded 19 Emergency Department (ED) visits and 65 total admissions, with some being direct admissions. Results showed that 89% of ED visits resulted in admission. Post-intervention, there were six (27%) ED visits for the same sample (n = 22), only 0.04% of which resulted in actual admission. Conclusions: Educating staff and implementing a PC referral process chronically and terminally ill patients may be an effective method of reducing readmission rates, thereby decreasing costs.


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