Systems Integration of Palliative Care into Nursing Homes

Topic: Palliative Care Models by Setting


Background: The New York State Delivery System Reform Incentive Payment Program (NYS DSRIP) aims to reduce avoidable hospitalizations and emergency department (ED) visits for Medicaid Beneficiaries. This initiative aims at reducing avoidable admissions by integrating primary palliative care (PC) practices into nursing homes (NH), clarifying goals of care and options, addressing pain and other symptoms, thus patients may require less hospital readmissions. 

Objectives: In the long term:

1) Integrate PC into practice model of participating NHs;

2) Provide education to patient-family-caregivers on PC services and their importance in healthcare;

3) Reduce avoidable readmissions/ED visits for Medicaid beneficiaries. Methods: Systems-level intervention initiated by New York Presbyterian Queens hospital (NYP/Q) to engage and collaborate with community NHs to provide primary PC services to seriously ill residents in NHs.

The NYP/Q Performing Provider System (PPS) recruited NHs and hospice agencies to participate. Project is co-chaired by director for transitions of care/case management and PC physician/leader, with strong administrative support. The PPS contracted or developed partnerships with community resources, including Hospices, to bring PC supports-services into NHs. PPS engaged NH staff in trainings to increase role-appropriate competence and comfort in PC skills.

 To provide primary PC education, the PPS team used AMA’s Education on Palliative and End-of-life Care (EPEC) training modules, providing CME-CEU accreditation for NH providers. EPEC covers 16 modules, including legal/ethical aspects of care, pain management, goals of care, advance care planning, and others. PPS promoted use of advance directives tools, eg, Medical Orders for Life-Sustaining Treatments (MOLST). PPS aimed to identify and engage PC champions at each NH and hospice agency.

 Results: Since April 2015, NYP/Q PPS has engaged 27 NHs and 6 hospice agencies to participate. The PPS is working with partners to provide education on primary PC skills to staff, monitor clinical quality metrics associated with pain management and advance directives, and engage patients and caregivers in PC services.  In Year 1 (4/1/2015 – 3/31/2016), PPS engaged 1,076 patients with 22 of the NH partners. In Year 2 to date (4/1/2016 – 6/30/2016), PPS engaged 598 patients with 20 of the NH partners. EPEC training began in Feb 2016, offered 2 modules at a time, with different NHs volunteering to host the training. Six modules have been taught so far, with positive feedback and attendance. Many NH physicians feel uncomfortable conducting basic PC conversations such as disclosing bad news, discussing goals of care, or end-of-life care. 

Conclusion: DSRIP is an innovative NYS initiative to improve care and reduce avoidable hospitalizations and ED visits. NYP/Q PPS was able to form a coalition of NHs and hospice agencies, and engage patients in PC.  It is too early to assess longterm outcomes such as avoidable readmissions. Next steps: Identify and engage PC champions at each NH and hospice agency. Pilot PCOS (Palliative Care Outcome Scale) tool at a partner NH, with goal of rolling out to all 27 NHs. Provide supportive basic education to NH physicians.


  • Cynthia X. Pan, MD
  • Chief, Division of Geriatrics and Palliative Care Medicine
  • Silvercrest Center for Nursing and Rehabilitation; New York Presbyterian/ Queens
  • 56-45 Main Street
  • Flushing, NY 11355
  • (718) 670-2434


  • Caroline Keane, RN, MSN, ANP, CCM
  • Sarah Kalinowski

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