This K23 application describes the background and experience of the applicant, Joan Gleba Carpenter, PhD, CRNP, ACHPN, and her plan to acquire the knowledge and training necessary to achieve her long-term goal: to become an independent clinical investigator in developing and testing effective nursing home delivery models of palliative care. Close to one-third of Medicare decedents use the Medicare skilled nursing facility (SNF) benefit in the 6 months prior to death. SNF care often increases the risk for more aggressive, potentially burdensome treatments and unrecognized or undertreated symptoms. Palliative care relieves suffering, enhances communication, and improves end-of-life care and decision making for seriously ill older adults. Palliative care consultation (PCC) is one approach that can potentially improve care for older adults with advanced illness in SNFs, but it is not widely available. To improve end of life outcomes for frail older adults and achieve independence, Dr. Carpenter has a developed a research and training plan in this application. The specific research aims are to: 1) Establish the feasibility and acceptability of the SNF-PCC intervention by determining: (a) percentage of all SNF patients who meet eligibility criteria; (b) percentage of eligible patients who consent to participate; (c) percentage of consented patients who receive the SNF PCC and from whom all data are collected; (d) clinician fidelity to the standardized SNF-PCC protocol (defined as 90% adherence to protocol elements), and (e) surrogate satisfaction with the consult (acceptability), defined as ratings of 4 and 5 on the Consultation Satisfaction Questionnaire (1-5 scale; higher scores reflect greater satisfaction); 2) Estimate the effect size of the SNF-PCC intervention on patient/family caregiver reported quality of life at seven days and 30 days post SNF-PCC in a pilot randomized controlled trial among 80 patients; and 3) Determine adherence to SNF-PCC recommendations at seven days and 30 days post SNF-PCC. The specific training objectives that will provide the knowledge and skills to complete the research aims are to: 1) expand understanding and application of the principles of transitional care, 2) develop and tailor clinical interventions, 3) acquire skills in palliative care clinical trials research, and 4) train in the ethical conduct of research. The research environment at the University of Pennsylvania features a number of high quality, well-established resources that will facilitate Dr. Carpenter's development. This proposal will provide the foundation for future clinical trials that test the effectiveness and implementation of palliative care interventions to enhance the care and outcomes for older adults with serious illness.
Palliative care is goal-directed, patient and family-centered care that focuses on a wide range of physical, psychosocial, and spiritual needs for persons with serious, life-limiting illnesses. Despite its association with improved quality of care, higher satisfaction, and better symptom management at the end of life, palliative care is not widely available to Medicare patients in the Skilled Nursing Facility (SNF) setting. The proposed research will test an evidence-based palliative care consult intervention derived from existing standards for older adult SNF patients in nursing homes.