Strategies to help reduce hospital readmissions

Palliative care programs:
 A resource for FPs


Action plans should include information that reinforces patients' daily self-care behaviors and instructions for what to do if symptoms get worse.The growth of palliative care programs in US hospitals has helped increase the emphasis on establishing goals of care. Inpatient-based palliative care consultation programs work with patients and families to establish goals. However, after discharge, many of these goals and plans begin to unravel due to gaps in the current health care model, including lack of follow-up and support.⁵⁰ Outpatient palliative care programs have begun to address these gaps in care.⁵⁰ Comprehensive palliative care programs are quickly becoming an important resource for FPs to help address transitional care issues.

CASE › When you ask Mr. and Mrs. T about his goals for treatment, they say are getting tired of the “back and forth” to the hospital. After discussing his lengthy history of worsening CHF and diabetes, you raise the idea of palliative care, including hospice, with the couple. They acknowledge that they have had family members get hospice care, and they are open to it—just not yet. In a "teamlet" model, health coaches meet with patients before and after the physician, and contact patients between visits.The 3 of you craft an “if-then” plan of care to use at home. You schedule a 2-week follow-up visit and remind Mr. T and his wife of your office’s 24-hour on-call service.

CORRESPONDENCE
Danielle Snyderman, MD, Department of Family and Community Medicine, Jefferson University, 1015 Walnut Street, Suite 401, Philadelphia, Pa 19107; danielle.snyderman@jefferson.edu