Facilitating Transfer to Hospice Care in a Community Hospital

Purpose: Implementing a third-party inpatient hospice program improves patient outcomes and reduces mortality rates, but the discharge-readmit workflow is complex and error prone. Learn how Stanford enhanced the standard discharge-readmit toolset to address these problems, with notable success at our community hospital.

Description: Integrating a comprehensive inpatient hospice care model within a community hospital involves multidisciplinary collaboration and teamwork among physicians, nursing, case management, social service, and community partners to be successful. It is a transformative approach to end-of-life care for a patients and their family, including bereavement process, that aligns with an academic framework to ensure rigorous, evidence-based standards.

This poster addresses the pressing need for compassionate, effective hospice care within community settings, a need that becomes even more critical as hospitals face increasing demands for quality end-of-life support. In alignment with Stanford Health Care's academic framework, this approach bridges high-quality patient care with a robust technical implementation of discharge-readmit toolset to guide the users in making it both practical and replicable.

In many community hospitals, hospice care services may lack standardization, often resulting in fragmented care, lack of early goals of care conversation with a patient and their family, unmet patient needs, and unnecessary hospitalizations that diminish patient quality of life. The challenge lies in establishing a model that not only provides compassionate end-of-life care but also integrates effectively with the existing medical and academic frameworks. This topic responds to that need, aiming to create a seamless, holistic approach that addresses both the emotional and medical needs of patients while reducing strain on hospital resources.

Implementing a GIP program with a hospice vendor requires two Epic encounters with unique HARs. Discharging patients from the original encounter and readmitting under a new HAR is a complex workflow with many moving pieces, and before implementing our novel solution for GIP, encounters often lacked a unique HAR and required manual chart correction post-discharge.

We partnered with our Epic inpatient and grand central teams to implement a novel order panel that automatically creates a pending preadmission with a unique HAR for the GIP encounter when the discharge-readmit order reconciliation tool is used. This innovative solution streamlines the technical components of this complex workflow and facilitates accurate admissions under the GIP service.

This model is innovative because it emphasizes a seamless integration of palliative practices within a community hospital, bringing interdisciplinary expertise to a traditionally underserved area. It leverages personalized care pathways and early intervention strategies to ensure patients receive timely, appropriate support, which not only enhances patient comfort but also reduces risk of unnecessary hospital admissions.

Outcome: Attendees will gain a detailed framework for implementing inpatient hospice care within a community setting, including strategies for aligning clinical practices with academic standards. By learning about early intervention methods, tailored care plans, and interdisciplinary collaboration, participants will be equipped to improve end-of-life care in their own hospitals. This approach not only enhances patient and family experiences but also optimizes hospital resources, ultimately leading to a more compassionate, effective, and sustainable model of care.