A quality improvement intervention to increase palliative care in nursing homes.

Context: Death is common in nursing homes, but access to palliative care is limited.
Objective: To test whether a quality improvement (QI) intervention in nursing homes increases hospice, pain management, and advance care planning.
Design and Setting: The QI intervention was tested in seven nursing homes using a prepoststudy design. Two additional nursing homes served as control sites.
Participants: Nine nursing homes serving 1169 residents.
Intervention: The intervention included recruitment and training of Palliative Care Leadership Teams in each facility, followed by six technical assistance meetings for team members. Hospice providers delivered six educational sessions for all nursing home staff using a structured curriculum. Teams received feedback of performance data on hospice enrollment, pain management, and advance care planning at 0, 3, and 6 months.
Main Outcome Measures: Percentage of residents receiving hospice or palliative services, pain assessment, pain treatment among residents in pain, and documented advance care planning discussions.
Results: Intervention facilities increased hospice enrollment from 4.0% of residents at baseline to 6.8% postintervention (p = .01) and increased pain assessments from 18% to 60% (p < .001). Among resident in pain, orders for nonpharmacologic pain treatments increased from 15% to 35% (p < .001), but pain medication use did not change. Residents with in-depth discussions about end-of-life care increased from 4% to 17% (p < .001). There were no significant changes in control sites.
Conclusions: A quality improvement intervention was effective in increasing hospice enrollment, pain assessment, nonpharmacologic pain treatment, and advance care planning discussions.