Date of Graduation

Summer 8-7-2018

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Nancy Taquino, DNP, RN, MSN, CNL

Second Advisor

Elena Capella, EdD, MSN/MPA, RN, CNL, CPHQ, LNCC


Standardizing the Palliative Care Referral Process

Problem: Heart failure (HF) is one of the most common causes of hospital admissions and emergency department visits in the United States. HF patients are at high risk for hospital readmission: 25% of HF patients discharged from the hospital are readmitted within 30 days of discharge, and 50% are readmitted within 6 months (Vedel & Khanossov, 2015).

Context: Palliative Care (PC) has been shown to be an effective way of managing distressing HF symptoms and thus of reducing hospital readmissions, yet patients are infrequently referred to PC services during their transition from hospital to home (Lowey & Liebel, 2016). Currently, there is no standardized referral process for patient care coordinators (PCCs) to refer HF patients to PC services.

Interventions: Standardized scripting was developed and implemented as a tool for PCCs to educate patients about the benefits of PC. Four PCCs implemented the intervention over the course of 30 days, and together, they identified 26 HF patients appropriate for PC referral.

Measures: Process measures include: the development and implementation of the standardized PC referral process; the number of completed PC referrals after utilization of the standardized PC referral process.

Results: Among the 26 patients identified, 22 (85%) received the PC standardized scripting, and of those 22 patients, 12 (43%) provided verbal consent to the PC referral and were referred to PC services. An incidental finding is that the PC team was very limited in way of providing PC services and in-depth educational symptom management to HF patients in the inpatient and outpatient settings related to staffing resources.

Conclusions: The use of standardized scripting was successful in increasing and stream-lining the referral process of HF patients to PC services. However, there is an opportunity for the PC team to optimize symptom management and improve clinical outcomes by way of hiring more PC physicians and nurses to initiate PC consult in the hospital and to continue the management of HF patients regularly in the outpatient arena. It may also be beneficial to assess a PC department at a facility of like size and demographics to evaluate and possibly emulate their processes & successes.