Implementing Automated Triggers to Identify Hospitalized Patients with Possible Unmet Palliative Needs: Assessing the Impact of This Systems Approach on Clinicians.

Background: Understanding patients' goals and values is important to ensure goal-concordant care; however, such discussions can be challenging. Little is known about the impact of having these discussions on hospitalists. Objective: To assess the impact on hospitalists of a system that reminds them to have serious illness conversations with their patients identified with potential unmet palliative needs. Design: Two group cohort trial. Setting/Subjects: Single academic center. Internal medicine hospitalist physicians, nurse practitioners, and physician's assistants. Measurements: Before the trial, all participants received serious illness conversation training. During the trial, hospitalists on intervention units received verbal notification when their recently admitted patients were identified using a computer algorithm as having possible unmet palliative needs. Hospitalists on the control unit received no notifications. At baseline and three months, hospitalists completed questionnaires regarding communication skill acquisition, perception of the importance of these conversations, and sense of the meaning gained from having them. Results: Both groups had similar improvements in their self-reported communication skills and experienced a small decline in how important they felt the conversations were. Neither group perceived having the discussions as being affectively harmful to patients. The intervention hospitalists, over time, reported a slight reduction in the sense of meaning they achieved from the conversations. Conclusion: Routinely informing hospitalists when their patients were identified as being at increased risk for unmet palliative needs did not increase the sense of meaning these providers achieved. It is likely the pretrial training accounted for many of the positive outcomes in communication skills observed in both arms of the trial.

Exploring Patients' Experience with Clinicians Who Recognize Their Unmet Palliative Needs: An Inpatient Study.

Background: Given the national shortage of palliative care specialists relative to the need for their services, engaging nonspecialists is important to ensure patients with serious illness have an opportunity to share their goals and values with their providers. Hospital medicine clinicians are well positioned to conduct these conversations given they care for many medically complex patients. Yet, little is known about the patient experience of inpatient goals and values conversations led by hospitalist teams. Objective: To assess patients' experience and perception of the quality of goals and values conversations. Design/Setting/Participation: Single center, tertiary care, nonrandomized, two group cohort trial of patients hospitalized on general medical inpatient units staffed by hospital medicine clinicians previously trained to conduct serious illness conversations. Intervention: An automated screening tool was used to identify patients at increased risk for unmet palliative needs. The multidisciplinary team was informed of the screen's results on the intervention units but not on the control units. Intervention unit clinicians were asked to consider talking with patients about their goals and values. Results: One hundred thirty patients participated in the study. The intervention patients reported improved quality of communication and fewer anxiety and depression symptoms compared with the control patients. Hospice utilization in addition to emergency department visits and hospital readmissions did not differ between the two groups. Conclusion: This study suggests that informing the care team regarding their patients' potential unmet palliative care needs is associated with patients reporting improved experience of their care without adverse effects on their mood.

Measuring Patient Preferences and Clinic Follow-Up Utilizing an Embedded Discharge Appointment Scheduler: A Pilot Study.

BACKGROUND: Scheduling timely outpatient follow-up appointments is part of a high-quality discharge process. In many centers, residents and hospitalists schedule follow-up appointments, often without patient input due to time constraints. METHODS: A needs assessment was conducted to quantify clinician time spent making discharge appointments and to identify barriers to successful appointment scheduling. A four-week pilot intervention subsequently embedded a discharge scheduler responsible for scheduling discharge appointments into five house staff teams. The goals of the pilot were to incorporate patients' scheduling preferences when making appointments, to improve appointment attendance, and to reduce administrative burden on residents. Results were analyzed using chi-square and Fisher's exact tests. RESULTS: Patients expressed a strong preference to be involved in scheduling follow-up appointments. In the intervention, there was a statistically significant increase in successfully scheduled appointments (66.7% vs. 87.7%; p < 0.0001) and attendance at follow-up appointments (43.9% baseline vs. 62.9% intervention; p = 0.011), a statistically significant reduction in rescheduled appointments (16.7% baseline vs. 4.9% intervention; p = 0.008), a nonsignificant trend toward increased number of canceled appointments (7.6% baseline vs. 17.5% intervention; p = 0.088), and no significant difference in no-show rates (18.2% baseline vs. 14.7% intervention; p = 0.544). Of residents involved in the pilot, 100% reported that the scheduler improved their ability to care for patients. CONCLUSION: This pilot suggests that adding a nonclinical team member tasked with scheduling discharge appointments improved alignment of the discharge process with patients' preferences and may be of value to residents, hospitalists, and the health care system.