Background

Elderly patients frequently experience deteriorating health after critical illness, which may threaten their independence and predispose them to unplanned hospital readmissions and premature death.

Objectives

To evaluate the operational feasibility of a 90-day home-based palliative care intervention in multimorbid elderly Veteran survivors of critical illness.

Methods

A multidisciplinary home-based palliative care intervention was provided for multimorbid elderly veterans who were discharged home after admission to the intensive care unit for sepsis, pneumonia, heart failure, or exacerbation of chronic obstructive lung disease.

Results

### Clinical Outcomes

Median PPS scores at day 90 (n = 11; median [IQR], 70% [50%-80%]) were slightly higher than the initial PPS scores (n = 15; median [IQR], 60% [60%-70%]; see Table). Consistently, median sESAS scores were slightly lower at day 90 (n = 11; median [IQR], 3 [2-4]) than the initial scores (n = 15; median [IQR], 4 [2-7]). Of the 11 patients who completed all visits, 3 (27%) were readmitted within 30 days and 7 (64%) were readmitted within 90 days. The median number of unplanned hospital admissions during the project period (median [IQR], 1 [0-2]) was similar to that of the 3-month period preceding index hospitalization (median [IQR], 1 [0-3]), whereas unplanned emergency department visits were lower during the project period (median [IQR], 1 [0-2]) than they were during the 3-month period preceding index hospitalization (median [IQR], 2 [2-4]); see Figure, part B). Patients rated their overall satisfaction with this intervention with a median (IQR) score of 4.5 (4-5) (n = 11) on a 5-point Likert scale.

We demonstrated operational feasibility of a home-based multidisciplinary intervention in multimorbid ICU survivors and reached our predefined goals of enrolling 15 patients within 12 months and completing at least 70% of prespecified visits. The importance of palliative care is highlighted by the fact that 1 patient transitioned to hospice during during the 90-day study period and 2 additional patients transitioned to hospice shortly after the 90-day study period. We observed improvements in physical functioning, quality of life, and symptom control, which contributed to high patient satisfaction. This intervention was time intensive and required multiple in-person and telephone visits by nurses, physicians, and social workers. Different models of care may be appropriate for different ICU survivors, and a resource-intensive intervention like this may be appropriate only for a subset of high-risk patients. On the basis of this experience, we recommend that future studies test efficacy, generalizability, and scalability; optimize efficiency by incorporating novel technology (telehealth visits); test alternative follow-up periods (eg, 60 days vs 90 days); and identify subgroups of ICU survivors who are most likely to benefit from home-based care interventions.

Our project has several limitations. First, it was designed as a quality improvement study to test the operational feasibility of implementing comprehensive home-based palliative care in multimorbid veterans. Although we were able to meet our enrollment criteria, the scalability of interventions like this will depend on the ability to automatize study procedures, for example, through EHR-prompted screening. Second, the median time to the first home visit was 8 days although it was planned to be 72 hours. Future studies of home-based interventions should aim to complete initial home visits as early as possible because the period immediately after hospital discharge is the most stressful and vulnerable time for patients and caretakers. Third, our project was conducted in the unique environment of the largest integrated health care system, and our findings may not generalizable to other more diverse settings. Fourth, we did not evaluate caregiver satisfaction during this project.

In conclusion, we successfully demonstrated the operational feasibility of a comprehensive home-based palliative care intervention in multimorbid elderly veteran survivors of critical illness at high risk of hospital readmission.

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

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## Footnotes

FINANCIAL DISCLOSURES

This work was supported with resources from and the use of facilities at the VA Pittsburgh Healthcare System. Florian B. Mayr is currently supported by a VA VISN4 Competitive Career Development fund and National Institutes of Health K23GM132688.

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