Preliminary Report of a Pilot Tele-Health Palliative Care and Bioethics Program for Residents in Skilled Nursing Facilities

Currently about 25% of Americans die in nursing homes, many with poorly controlled pain and other symptoms, with minimal provisions for psychosocial support. New models are necessary to lessen structural and process barriers to give effective end-of-life care in nursing homes. Objectives: 1) To extend hospital-based Bioethics Consultation Services (BCS) and Palliative Care Services (PCS) at Montefiore Medical Center (MMC) in the Bronx to two local Skilled Nursing Facilities (SNFs), Morningside House Aging in America (MSH) using direct face-to-face consultations and Beth Abraham Health Systems (BAHS) via video consultations (VC); 2) Achieve improvements in quality of life and comfort for elderly residents and their families; 2a) Improve the level of practice and increase staff satisfaction with palliative care content-related knowledge and bioethical analysis. Methods: We report preliminary findings of this two group quasi experimental project with results of pre- and post- tests rating content-related knowledge in aspects of end-of-life care for staff. Select pre-test and post-test questions were given to physicians and other staff, but were re-configured for, registered and licensed practice nurses, social workers, and certified nursing assistants from the End-of-Life Physician Education Resource Center (EPERC). Patient, family, and staff ratings of the quality of palliative care were measured with a Palliative Outcomes Scale (POS) one week prior to and post consultation. Results: 72 staff attended in-services; 53 completed pre-tests and 49 post-tests. Overall knowledge scores increased for 9 of the 16 items that were analyzed. There were improvements in knowledge scores in 12 of 16 items tested for staff content related knowledge which were statistically significant in regard to management of cancer pain from 63.8% to 81.5% (p = 0.03) and a trend to significance for assessment and management of delirium from 31.6% to 61.9% (p = 0.073). Seventy five POS surveys were completed from 13 video-conferenced Palliative Care consultations and 14 direct face- to-face consultations from March 2008 to January 2009. There were improvements in ratings for some aspects of quality of care on the POS. Patient and staff aggregate response scores for the POS were significantly improved between baseline and follow-up (Wilcoxon signed-rank test p = 0.0143 and p = 0.005) at the videoconsultation site and for family and staff at the face-to-face consultation site (Wilcoxon signed-rank test p = 0.0016 and p = 0.0012). Conclusion: Preliminary evidence suggests that use of real time videoconferencing to connect hospital-based Bioethics and Palliative Care clinicians with patients, families, and staff in Skilled Nursing Facilities may enhance some aspects of end-of-life care for their residents, as well as content related knowledge in core aspects of end-of-life care for interdisciplinary groups of staff or caregivers.