Collaborative home-based palliative care model helps people die at home rather than hospital

Patients with chronic heart failure who received collaborative, home-based palliative care were less likely to die in hospital and more likely to die at home than people who received usual care, according to new research in Canadian Medical Association Journal (CMAJ).

In Ontario between 2010 and 2015, 75% of people with heart failure died in hospital despite the majority preferring an out-of-hospital death.

The current CMAJ study included 245 people in Ontario with chronic heart failure between 2013 and 2019 who were enrolled in the collaborative care model and 1172 who received usual care. The mean age was 88 years, and 55% were female.

The collaborative model, which involved primary care providers, cardiologists and palliative care specialists, was associated with fewer visits to the emergency department, fewer admissions to hospital and intensive care near the end of life, and a lower likelihood of dying in hospital (41% v. 78%) than usual care. The model emphasized advance care planning; home-based management of heart failure; standardized protocols for clinical care; education of patients, families and clinicians; and collaboration between health care professionals.

"The implementation and scalability of this model does not require major restructuring for providers," says Dr. Kieran Quinn, a palliative care physician with Sinai Health and the University of Toronto, Toronto, Ontario. "However, scalability does require increased awareness on the part of all providers of the potential to provide integrated palliative and heart failure care."

"This model coincided with a regional cultural shift among palliative care physicians, cardiologists and other health care providers, and people living with heart failure and their family caregivers," says Dr. Sarina Isenberg, Bruyère Chair in Mixed Methods Palliative Care Research at Bruyère Research Institute and the University of Ottawa. "The clinical leads of the model worked tirelessly to affect these changes in skills, behaviours and attitudes, and champions are needed to expand to other regions."

A related editorial calls for widespread adoption of this model to help patients with a variety of diseases who live in the community as well as people in long-term care facilities who might benefit.

"My hope is that Quinn and colleagues will widely share the details of their care pathways and training modules, and that practitioners and health care managers in regions across the country will see the benefits of providing high-quality collaborative palliative care at home for patients with severe heart disease (and other diseases)," writes Dr. Andreas Laupacis, deputy editor, CMAJ. "It's time to make this happen."

He suggests changed funding models to include postdischarge care, in which hospitals share funding with community partners who would coordinate and deliver care.

The study was conducted by researchers from the Ottawa Hospital Research Institute, Bruyère Research Institute, University of Ottawa, Ottawa; University of Toronto, ICES and Sinai Health, Toronto, Ontario; Emory University, Atlanta, Georgia.