Learning Objective #1: Describe four stretegies by which guideline-driven palliative care interventions can be integrated into home health nursing practice

Learning Objective #2: Give four examples of specific outcomes that can be measured to evaluate efficacy of practice changes

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Several years ago, the management team of a rural home health agency identified the need to increase staff competency in palliative care. Clinical practice guidelines in palliative and end of life care provided the basis for competency development and practice change. Research utilization and translation of evidence based guidelines into practice are especially challenging in rural areas which are isolated from academic health centers, university-based schools of nursing and centers of health care research. The home care setting presents the additional barrier of a dispersed work force with limited opportunities for peer support, mentoring and coaching. Several strategies were employed to implement clinical guidelines: 1. Management support: In July 2000, the Administrator, VP Operations and Medical Director endorsed the "5 Precepts of Palliative Care" as developed by the Last Acts Task Force and embraced them in the organizations philosophy of care. 2. Education: The entire staff (nurses, nursing assistants, therapists, office staff) completed the EPEC curriculum under Medical Director leadership. (EPCE = Education on Palliative and End of Life Care.) 3. Coaching and mentoring: Interdisciplinary team meetings, RN meetings and individual consultation provided opportunities to discuss and evaluate palliative care interventions. 4. Changes in practice environment: Examples of changes enabling guideline implementation are: revised policy on death in the home which involved local police department; use of CCO-DNR bracelets, which included education of local physicians; relationship with and understanding of Hospice and the Hospice medicare benefit. 5. Monitoring: Outcomes monitored over three years included deaths in home, deaths in hospital, number using CCO-DNR bracelets, number transferring to Hospice and number referred to but denied by Hospice. Data were further evaluated to determine why patients transferred to the hospital for anticipated death and why patients refused transfer to Hospice.