Breaking the Cycle: Using Serious Illness Communication to Optimize Care Transition Planning in Serious Illness

Tamra Keeney; Jaclyn Shameklis; Alexis Drutchas; Joanna Paladino; Elizabeth Lindenberger; Christine Ritchie; Brook Calton

doi:10.1016/j.jamda.2023.10.004

Breaking the Cycle: Using Serious Illness Communication to Optimize Care Transition Planning in Serious Illness

J Am Med Dir Assoc. 2023 Nov 7:104853. doi: 10.1016/j.jamda.2023.10.004. Online ahead of print.

Authors

Tamra Keeney¹, Jaclyn Shameklis², Alexis Drutchas², Joanna Paladino³, Elizabeth Lindenberger², Christine Ritchie⁴, Brook Calton⁵

Affiliations

¹ Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, MA, USA; Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, MA, USA; Continuum Project, Massachusetts General Hospital, Boston, MA, USA. Electronic address: TKeeney1@mgh.harvard.edu.
² Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, MA, USA; Continuum Project, Massachusetts General Hospital, Boston, MA, USA.
³ Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, MA, USA; Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, MA, USA; Continuum Project, Massachusetts General Hospital, Boston, MA, USA.
⁴ Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, MA, USA; Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, MA, USA.
⁵ Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, MA, USA.

PMID: 37949431
DOI: 10.1016/j.jamda.2023.10.004

Abstract

It is widely recognized that many older adults in their last year of life will cycle between hospitals and skilled nursing facilities-a phenomenon described as "rehabbing to death." Several strategies to address this complex problem have been proposed, including developing and testing serious illness communication models to provide goal-concordant care by aligning what matters most to patients with how they spend their time in the last months of life. Serious illness communication (SIC) includes structured skills clinicians can use with patients and caregivers to assess illness understanding, goals and values, share information, and make recommendations. Despite the potential of SIC models, there is a lack of literature focused on developing and testing SIC strategies in the context of care transition planning for older adults with serious illness. Our interprofessional team developed "Rehabbing to Death: Practical Strategies to Optimize Care Transitions for Patients with Serious Illness," an evidence-based, interprofessional SIC training curriculum for hospital-based rehabilitation clinicians. This 3-session curriculum was designed to enable rehabilitation clinicians to acquire knowledge of trajectories and outcomes for patients living with serious illness and communication skills to use with patients, families, and interprofessional colleagues. Nine rehabilitation clinicians (n = 3 equally from Physical Therapy, Occupational Therapy, and Speech-Language Pathology) participated in our pilot. Sessions were highly attended [100% (n = 9) sessions 1 and 2, 89% (n = 8) session 3]. Participants who completed the curriculum reported increased self-rated confidence in knowledge of serious illness and ability to communicate prognostic information and recommendations for care transitions with patients, families, and colleagues. In addition, 78% of participants would recommend the curriculum to a colleague and strongly agreed that curricular content and skills were relevant to their clinical practice. Pilot results suggest that implementing an SIC curriculum for hospital-based rehabilitation clinicians is feasible, given high rates of completion and satisfaction.

Keywords: Post-acute care; rehabilitation; serious illness communication; skilled nursing facility.