Date of Graduation

Summer 8-4-2026

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)

College/School

School of Nursing and Health Professions

Program

Kaiser cohort MSN capstone

First Advisor

Dr. Dave Ainsworth

Abstract

Problem: In this home health palliative microsystem, many seriously ill patients begin care without timely goals‑of‑care conversations or documented advance directives, leading to fragmented communication and potentially avoidable emergency visits and rehospitalizations.

Context: This quality improvement project took place in a hospital-based home health palliative care program in Northern California, where an interdisciplinary team identified inconsistent Life Care Planning (LCP) practices and variable staff comfort with conducting goals‑of‑care discussions.

Intervention: A structured LCP workflow was developed so that newly admitted palliative home health patients receive a goals‑of‑care discussion and advance directive review within 7 days of start of care, using standardized patient identification, a conversation guide, dedicated electronic documentation fields, and a brief pre‑visit chart review, refined through plan–do–study–act cycles.

Measures: The primary outcome was the percentage of new palliative home health admissions with documented goals‑of‑care conversations and advance directive status within 7 days; a secondary outcome was unplanned acute care utilization within 3 months. Process and balancing measures monitored use of the LCP workflow, visit length, and perceived clinician burden.

Results: During the three-month implementation period, timely documentation of goals-of-care conversations and advance directive status improved steadily from a baseline of 50% (5 of 10 patients) to 57% in Month 1, 67% in Month 2, and 71% in Month 3, achieving the project goal during the final month of implementation. Pre-visit chart review and standardized workflow reliability also improved, all staff completed workflow education, and preliminary acute care utilization trended downward from 40% at baseline. Because patients admitted later in the implementation period had not completed a full three-month follow-up, utilization findings remain preliminary.

Conclusion: Embedding a structured LCP workflow into routine home health palliative visits can increase early, consistent goals‑of‑care discussions, strengthen documentation of patient preferences, and support more goal‑concordant, home‑based care while helping to reduce crisis‑driven acute care use at the end of life.

Keywords: life care planning, home health palliative care, hospitalization reduction in palliative care, symptom management in home health palliative patients, advance care planning, goals of care.

Download

Share

COinS