Abstracts from Center to Advance Palliative Care National Seminar Palliative Care Everywhere: Bridging the Gaps November 12–14, 2015 San Antonio, TX

Abstract

Care Team has provided service in the Twin Cities, MN, community for 8 years. The team is composed primarily of eight specially trained home health nurses who make home visits, with twice monthly IDT collaboration with MD, social worker, and spiritual care. The team successfully provides expert symptom relief and coordination of care for patients with complex illness who continue life-prolonging treatment, with high rates of referral to hospice when warranted by the patient's condition and goals of care. This year we are collecting data on hospital readmissions, with dramatic reductions measured for patients receiving palliative care. Patients assessed as higher risk and worse prognosis by OASIS screen showed the greatest benefit. Results: For patients with temporary at-risk status with return to normal health, readmission rate is 12.1% with no PC, and 3.7% with PC. For patients at high risk and fragile status, readmission rate is 21% with no PC, and 5.6% with PC. For patients in serious condition and with prognosis less than one year, readmission rate is 33.9% with no PC, and 2.6% with PC. This is the grand total for January to June 2015, and we continue rolling data, which can be updated at the time of poster presentation.