A team of professionals provides palliative care patients with in-home, quality care to prevent readmissions.

• The program’s electronic medical record (EMR) makes it easy for case managers and others to share notes with all providers involved in a patient’s care.

• Case managers team up with primary care providers and other physicians to optimize patient care decisions.

• Nurses provide triage for which patients can be seen at home and which should return to the clinic for a physical exam.

A North Carolina palliative care program employs doctors and other members of a healthcare team to help keep patients out of the hospital through in-home, quality care.

The following is how the program works:

• Identify patients through referrals. “We are a specialty service, where providers can put in a referral for palliative care at home,” says Robin Motley, MSN, FNP, a home-based palliative care nurse practitioner at University of North Carolina (UNC) Palliative Care at Home.

“If a primary care provider [PCP] or specialist thought their patient had palliative care needs and would benefit from us making routine visits in the home or a one-time visit, we could go out, take a look, and do an in-home assessment,” she explains. “Typically, what we tell providers is if you have someone with multiple chronic illnesses and symptoms that are not well-managed and they have difficulty getting in to see you, or high utilization, it would be appropriate to refer us, and we could augment their care with an added layer of support in the home.”

• Use technology to improve communication. The program uses an electronic medical record (EMR) to engage everyone in the patient’s care.

“At the end of my visit, I can send a copy of my visit notes to every member of the care team,” Motley says. “Additionally, through the EMR, I can send a direct message to a particular provider if I have a specific question or concern and want to let them know something.”

For example, if Motley were seeing a patient with chronic obstructive pulmonary disease (COPD) and she were worried about the patient’s coughing and congestion signifying a flare-up, she could send the patient’s doctor a quick message about the symptoms.

“I could let the doctor know that I will treat the patient for COPD with steroids and will follow up in X period of time,” Motley says. “The patient would know to call me if the symptoms got worse.”

• Work as a team with PCP. “We work as a team with patients’ primary care providers, but we do not replace the PCP,” Motley says. “We also work very closely with patient specialists.”

For example, Motley might have a patient with painful arthritis of the knees, and the patient has been seeing a sports medicine provider for steroid injections.

“During visits, I might find that her pain is flaring up and the things I’ve recommended are not as helpful as I’d like them to be,” she says. “So I might reach out to her sports medicine physician.”

In another example, Motley might contact a patient’s cardiologist if the patient is experiencing cardiac symptoms and fluid overload.

“I might say, ‘Here’s what I’m thinking about changing [in] the medication regimen. What are your thoughts?’” she says. “We are highly collaborative, and our goal is to work with patients and their providers to manage symptoms so they are well controlled and patients can avoid going to the hospital and being uncomfortable.”

• Nurses triage patients for home visits. “We have two RNs at our office who triage and are very familiar with all of our patients,” Motley says. “If a patient calls us with a problem or symptom, a nurse will triage that and, if needed, talk with one of the providers.”

The nurses decide whether a patient needs to be seen at home, she adds.

When patients visit a clinic, the environment is conducive to a physical exam, blood draws, and other diagnostic tests. In-home visits might have poor lighting and less space, and examining patients might require creativity, Motley notes.

“On the flip side, you get so much more information when you get into a patient’s home,” she says. “We can see gathered rugs or clutter that might be a fall risk. We know what medications they have, and we can see whether they have heat, running water, food, and security.”

Providers who see patients in a clinic might not get the full perspective.

• Visits depend on the patient’s acuity and symptoms. After the initial visit, the nurse will schedule follow-up visits in one or more months, depending on the patient’s acuity level and symptoms, Motley says.

“We might start someone on an antidepressant, for example, and follow up with the patient,” she explains. “Then when things are stable, we try to see patients every one to three months.”

When patients are doing well and do not need symptom management, they still are high-risk, so the team will keep in touch, she adds.

Most of the patients have serious chronic illnesses, and many of them will transition to hospice care or go into the hospital, where they will die from complications of their diseases, she says.

“Some patients do have symptoms that are adequately controlled, and they no longer need us,” Motley says. “So we discharge those patients for now — and if they need us in the future, we’re happy to come back.”