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Introduction: Studies show that home-based palliative care (HBPC) improves participant outcomes and satisfaction with care while also decreasing hospitalizations and emergency department visits. U.S. health care payment reforms create financial opportunities to offer HBPC. Consequently, more HBPC programs are emerging, heightening the need to evaluate their effectiveness. Methods: This randomized, controlled trial is comparing the effectiveness of an evidence-based model of HBPC and enhanced usual primary care for participants who receive primary care from medical groups and clinics organized under an accountable care organization or Medicare Advantage plan. Palliative care services are reimbursed by our partnering health plan provider. The five-year trial will enroll 1155 seriously ill participants (and ∼884 of their caregivers) with heart failure, chronic obstructive pulmonary disease, or advanced cancer. We are collecting data via telephone surveys with participants at baseline and one and two months postenrollment and with caregivers at baseline, one and two months postenrollments, and following the death of a loved one. We are collecting participant-reported outcome measures of pain, symptoms, anxiety, depression, participant-provider communication, and hope. Caregiver outcome measures include caregiver burden, communication with providers, anxiety, and depression. Additional outcomes are participant survival time and participants' emergency department visits and hospitalizations. Study Implementation: Challenges and Contributions: Our research team has encountered several significant challenges in early study implementation. These include engaging primary care providers in the study and coordinating logistics with a health plan. Both challenges have contributed to a lag in participant enrollment. Despite these challenges, our study holds tremendous promise to accelerate adoption and spread of an evidence-based HBPC model across the country. [ABSTRACT FROM AUTHOR]

Recognition of the difficulties involved in replicating evidence-based interventions is well documented in the literature within the medical field. Promising research findings are often not translated into practice, and if they are, there is a significant time gap between study conclusion and practice adoption. The purpose of this article is to describe the barriers and facilitators encountered by two managed care of organizations while replicating an evidence-based end of life in-home palliative care model. Using Diffusion of Innovation Theory as a theoretical framework, results from focus groups and interviews with the project's clinical, administrative and research teams are presented and recommendations made for improving translational efforts. The process of replicating the end of life in-home palliative care model clearly illustrated the key elements required for successfully diffusing innovation. These key elements include marketing and communication, leadership, organizational support and training and mentorship. This qualitative process study provides clear, real world perspectives of the myriad of challenges encountered in replicating an evidence-based project. [ABSTRACT FROM AUTHOR]

Purpose: To examine differences in site of death and costs of services by primary diagnosis for patients receiving home-based palliative care as compared to usual care at the end of life. Design and Methods: A nonequivalent group design was employed with 298 terminally ill patients diagnosed with cancer, CHF, or COPD enrolled. The treatment group received an interdisciplinary home-based palliative care program and the comparison group received usual Kaiser Permanente services. Data collected included patient demographics, Severity of illness, service use, and site of death. Results: Among all diseases, patients enrolled in palliative care were more likely to die at home. Enrollment in palliative care was significant associated with cost reductions for patients with cancer, COPD, and CHF. No significant difference was found between diagnostic groups in terms of magnitude of cost savings. Implications: Provision of interdisciplinary home-based palliative care at end of life can effectively increase the likelihood of dying at home for patients with CHF, COPD, and cancer while realizing, significant cost savings. [ABSTRACT FROM AUTHOR]

Medication errors are common among older adults, particularly among those who are at heightened risk due to transfer between care settings. Determining accurate medications for hospitalized patients is a complicated process. This paper presents findings from a small pilot study conducted to identity medication documentation problems at the point of hospital discharge among older adults and the problems encountered in developing new technological systems to address these problems. A prospective study was conducted within a managed care medical center that included patient and physician surveys and chart reviews. A review of 104 medical records revealed several problems in the documentation of patient medication including legibility, use of medical abbreviations and incomplete and missing entries. While patients overall were satisfied with medications communication efforts at discharge, physicians surveyed reported that these methods were inadequate in transmitting medication lists to primary care physicians, patients and other care providers. Patients reported taking more drugs than what were listed in the medical record. These findings led to the development, testing, and implementation of an electronic medication sheet. Despite the success in developing this new system, few physicians engaged in its use, with most preferring to continue with their standard discharge practices of written communication. [ABSTRACT FROM AUTHOR]

Context: Despite the widespread recognition of the need for new models of care to better serve patients at the end-of-life, little evidence exists documenting the effectiveness of these models. Objective: To evaluate the effectiveness of a palliative program for end-of-life care. Design: A comparison group study was conducted between March 1999 and August 2000 comparing subjects enrolled in a palliative care intervention to those receiving usual care. Setting: Home Health Department at Kaiser Permanente, TriCentral Service Area. Subjects: During the course of the 2-year study, 558 subjects were enrolled. A subgroup of 300 patients who had died during the course of the study was selected for analysis; 161 were enrolled in the Palliative Care Program and 139 in the comparison group. Intervention: The Kaiser Permanente Palliative Care Project is a multidisciplinary care management approach for home-based end of life care and treatment. The program is designed to facilitate the transition from acute to palliative care during the last 12 months of life with the goal of improving quality of life through the provision of symptom control and pain relief, emotional and spiritual support, and patient education. Main outcome measures: Medical service use and satisfaction with services. Results: Palliative care patients had increased satisfaction with services at 60 days after enrollment and significantly fewer emergency department visits, hospital days, skilled nursing facility days, and physician visits than those in the comparison group. Those enrolled in palliative care averaged a 45% decrease in costs as compared to usual care patients. Conclusion: Through integrating palliative care into curative care practices earlier in the disease trajectory, chronically ill patients nearing the end of life report improved satisfaction with care and demonstrate less acute care use resulting in lower costs of care. In addition, patients enrolled in the palliative care program were more likely to die at home than comparison group patients. [ABSTRACT FROM AUTHOR]

Presents letters to the editor on various medical topics as of May 1, 2002. Treatment of congestive heart failure; Postmenopausal hormone replacement, body mass index, and quality of life; Varicella vaccine and shingles; Chocolate consumption and platelet function.

Discusses the advantages of managed care organizations (MCOs) in developing long-term end-of-life care. Problems related to unmanaged care; Coordination of medical care across MCOs; Development of long-term and end-of-life care at Kaiser Permanente.

Currently, single loop learning is the predominant method of problem solving orientation engaged in by healthcare institutions. This mode of learning is not conducive to fostering needed communications between health care providers and terminal patients. Reflection in action, second loop learning, focuses on deep listening and dialogue and can be critical in opening communications paths between the dying patient and his or her caregivers. This article discusses organizational learning theory and applies the theories double loop learning technique of reflection in action to end-of-life care. The article further explores an exemplar of reflection in action in a Palliative Care Program, and end-of-life home care program at Kaiser Permanente. In order to more effectively meet the needs of terminally ill patients, greater efforts are needed to incorporate second loop learning into the practice of those caring for these patients. [ABSTRACT FROM PUBLISHER]

Objectives: To identify factors associated with physician referrals to end-of-life (EOL) care., Study Design: Cross-sectional, web-based survey., Methods: Participants were managed care physicians (n = 545) from the Southern California region of a national nonprofit health maintenance organization who treated a patient in their office within 6 months of the patient's death from a chronic condition. Measures included self-reports of referrals to EOL services, comfort level discussing EOL with patients, personal/family experience with hospice, and demographic characteristics., Results: Participants were most commonly US born (69.1%), married (83.8%), and male (66.0%) with a mean age of 47 years (SD = 8.9 years). About half were Caucasian (51.7%). Logistic regression revealed that family/internal medicine physicians were nearly 9 times more likely to make EOL referrals (95% confidence interval [CI] 3.879-19.434), and physicians comfortable discussing EOL care were nearly 7 times more likely to refer (95% CI 3.465-12.750). Younger age was significantly associated with EOL referrals; with every 1-year decrease in age, physicians were 5% more likely to refer (95% CI 0.911-0.985). Family/internal medicine physicians (95% CI 1.259-2.899) and those comfortable discussing EOL care (95% CI 2.964-9.685) were also more likely to make frequent (4 or more) referrals, Conclusions: This study highlights factors associated with EOL referrals that may be enhanced at the organizational level through training and educating physicians. Results suggest that organizations should work toward improving physician ease and comfort with EOL conversations. This study serves as an important step toward understanding and reducing physician-level barriers to EOL referrals.

Kaiser Permanente (KP) has been a pioneer in the development of hospice services in the United States. Since 1978, when hospice services were introduced in the KP Southern California Region, they have been gradually expanded to benefit thousands of patients and their families. However, important barriers to timely, appropriate utilization of hospice care remain. A pilot project conducted in our TriCentral Service Area has shown that palliative care-a newer development in end-of-life care-can be cost-effective in addition to being beneficial for patients and their families. Efforts are underway to emulate this model of care at other KP facilities. Availability of both home-based and inpatient palliative care services can expand the number and type of patients who, as they near the end of life, can benefit from effective symptom control and other support.