Determining the optimal referral for patients with serious illnesses like COPD, heart failure, cancer, or dementia involves assessing their current disease stage and care needs. Streamlining the continuum of care between home health, palliative care, and hospice requires understanding their distinct levels of support and eligibility criteria.

Home Health Service

Home health services focus on treating illnesses or injuries in patients with restorative potential. They include skilled services like wound care, injections, and monitoring health status but may not address higher-level clinical or psychosocial needs.

Palliative Care Service

Palliative care, suitable for patients less responsive to disease treatments with a prognosis of 18 months or less, offers expert case management aligned with patients’ care plans and values. It emphasizes comfort and quality of life while guiding patients and primary care physicians through care preferences and advanced care planning.

Recognizing signs of ongoing decline, increased healthcare utilization, or complex home requirements may indicate the need for a palliative care referral.

Hospice Service

Hospice, designed for patients no longer benefiting from disease treatments and with a prognosis of six months or less, delivers personalized care through interdisciplinary teams. It provides 24/7 clinical support, symptom management, and psychosocial and spiritual assistance, aiming to enhance quality of life while minimizing hospital visits.

The Conversation

Initiating meaningful conversations about care options with patients and their families is a cornerstone of patient-centered healthcare. These discussions hold particular importance during key touchpoints such as annual wellness visits or follow-ups after hospitalization. These moments provide a valuable opportunity to engage patients in proactive care planning and ensure their preferences are respected as their illness evolves.

During annual wellness visits, healthcare providers can engage patients in discussions about their overall health and well-being. This is an ideal time to broach topics related to advance care planning, including preferences for future medical care and end-of-life decisions. By starting these conversations early, patients have the opportunity to reflect on their values and goals, empowering them to make informed decisions about their healthcare journey.

Similarly, post-hospitalization follow-ups offer a critical opportunity to assess patients’ recovery progress and address any ongoing concerns. These visits provide a natural segue into conversations about care options, particularly for patients with chronic or serious illnesses. By discussing potential treatment pathways, including palliative care or hospice, healthcare providers can ensure that patients and their families are well-informed and supported in making decisions aligned with their values and preferences.

Decisions

Incorporating these discussions into routine healthcare encounters helps foster trust and collaboration between patients and healthcare providers. It ensures that patients feel empowered to voice their concerns and preferences, leading to more personalized and compassionate care throughout their illness. Referring patients to palliative care early maximizes the benefits of longer support and facilitates a seamless transition to hospice when needed.